UC-NRLF 


B    3    135    b?E 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 
MRS.  PRUDENCE  W.  KOFOID 


ELEMENTS 


OF 


GENERAL    PATHOLOGY 


ELEMENTS 


OF 


GENEKAL  PATHOLOGY 


BY   A.   F.    CHOMEL, 

PROFESSOR   OF    CLINICAL    MEDICINE    TO   THE    FACULTY   OF    PARIS  J     CONSULTING   PHYSICIAN 

TO  THE   KING  J    PHYSICIAN   IN   ORDINARY  TO  THE  PRINCESS   ROYAL  J    OFFICER   OF 

THE    LEGION    OF  HONOR  ;     HONORARY   PHYSICIAN    OF    THE   HOSPITALS  } 

MEMBER     OF    THE   ROYAL    ACADEMY    OF    MEDICINE  J     AND 

OF    MANY     OTHER    ACADEMIES    AND    LEARNED 

SOCIETIES,   NATIONAL  AND  FOREIGN. 


Melius  est  sistere  gradum  quam  progredi  per  tenebras.  —  GAUBIUS. 


THIRD    EDITION,    CONSIDERABLY    ENLARGED. 


TRANSLATED   FROM    THE   FRENCH 

BY  F.  E    OLIVER,  M.  D.,  AND  W.  W.  MORLAND.  M.  D., 

Members  of  the  Massachusetts  Medical  Society. 


BOSTON: 
WILLIAM  D.  TICKNOR  AND  COMPANY. 

CORNER     OF    WASHINGTON    AND    SCHOOL    STREETS. 

M  DCCC  XLVIII. 


Entered  according  to  act  of  Congress,  in  the  year  1847,  by 

F.  E.  OLIVER,  AND  W.  W.  MORLAND. 
in  the  Clerk's  Office  of  the  District  Court  of  the  District  of  Massachusetts. 


BOSTON: 

PRINTED  BY  THURSTON,  TORR  Y  AND  CO. 
31  Devonshire  Street. 


k-RBl) 


Bio 


TO 


JAMES  JACKSON,   M.  D. 

PROFESSOR    EMERITUS    OP    THEORY    AND     PRACTICE    OP    PHYSIC    IN     HARVARD    UNIVERSITY, 
HONORARY  MEMBER  OP  THE  ROYAL  MEDICAL  AND   CHIRURGICAL  SOCIETY,  ETC.  ETC., 


DISTINGUISHED     ALIKE     FOR     HIS    PRIVATE     VIRTUES,     PROFESSIONAL    EMINENCE, 

AND    HIS    UNWEARIED    AND    INVALUABLE    LABORS    IN    THE 

CAUSE    OF    MEDICAL    SCIENCE, 

THIS    TRANSLATION 

IS,   BY    PERMISSION, 
MOST     RESPECTFULLY     DEDICATED. 


TRANSLATORS'     PREFACE. 


THE  classical  work  now  first  presented  to  the  medical  public 
in  the  form  of  a  translation,  can  need  no  other  recommendation 
to  secure  its  cordial  reception,  than  the  name  and  reputation  of 
its  celebrated  author.  We  may  hazard  an  expression  of  surprise 
that  it  has  so  long  remained  unclothed  with  a  garb,  which 
would  have  introduced  it  more  universally  to  the  profession  in 
this  country.  With  precepts  of  inestimable  value  to  the  student, 
it  combines  a  vast  collection  of  details  interesting  to  the  practi- 
tioner. Whoever  has  followed  the  author  in  his  clinical  practice, 
and  remarked  his  admirable  qualities  as  a  diagnostician  of  dis- 
ease, his  unfailing  detection  of  the  most  obscure  symptoms,  his 
accurate  prognosis,  and  remarkable  skill  in  exhibiting  and  ex- 
plaining cadaveric  lesions,  will  readily  discover,  in  the  present 
work,  the  reflection  of  his  practical  labors. 

We  trust  that  our  task,  by  no  means  a  light  one,  has  been,  at 
least,  faithfully  performed.  The  few  additions,  in  the  form 
of  notes,  relate  chiefly  to  new  discoveries  in  medical  science, 
announced  since  the  appearance  of  the  last  French  edition,  or 
to  questions  still  undecided,  and  consequently  open  to  remark. 

BOSTON,  NOVEMBER  12,  1847. 


AUTHOR'S    PREFACE. 


GENERAL  PATHOLOGY  treats  of  diseases  considered  abstractly, 
or  in  regard  to  that  which  is  common  to  them  all.  It  serves  at 
once  as  introduction  and  sequel  to  special  or  descriptive  pathol- 
ogy, whose  end  is  the  knowledge  of  each  particular  malady  to 
which  man  is  subject.  It  comprehends  all  that  is  most  simple, 
and  likewise  what  is  most  elevated  in  science ;  on  the  one  hand, 
the  definition  of  terms  and  the  description  of  the  phenomena  of 
disease ;  on  the  other,  the  discussion  of  all  those  fundamental 
questions  and  the  exposition  of  those  general  principles,  which 
are  to  guide  the  physician  in  the  arduous  practice  of  a  pro- 
fession closely  connected  with  the  dearest  interests  of  humanity. 
General  Pathology,  consequently,  comprises  within  itself  the 
most  unpretending  elements  and  the  most  exalted  philosophy  of 
medicine. 

In  this  new  edition  we  have  not  departed  from  the  plan  and 
rules  which  were  adopted  in  those  preceding  it.  We  have 
treated  of  disease  in  general,  as  we  should  of  any  one  malady 
in  particular,  when  intending  to  give  the  most  complete  account 
of  it  possible. 

The  definition  of  disease  in  general,  and  the  mode  of  defining 
each  one  in  particular  ;  the  nomenclature,  seat,  causes,  and 
precursory  phenomena  of  diseases;  their  symptoms,  progress, 
duration,  and  varied  terminations;  convalescence,  consecutive 
phenomena,  relapse,  and  recurrence ;  the  distinction  of  genus, 


x  AUTHOR'S   PREFACE. 

of  species,  and  of  pathological  varieties ;  complications,  diag- 
nosis, prognosis,  anatomical  changes,  and  treatment ;  the  inti- 
mate nature  of  diseases,  their  classification,  and  the  examination 
of  the  principal  works  upon  general  pathology,  are  each  the 
subject  of  a  special  chapter. 

We  resolved,  in  the  first  edition  of  this  work,  to  abstain  from 
any  systematic  idea,  and  to  adhere  strictly  to  the  narration  of 
facts,  and  the  consequences  rigorously  deduced  from  them.  We 
dare  not  flatter  ourselves  that  we  have  completely  accomplished 
this,  but  perhaps  may  be  permitted  to  think  that  a  near  ap~ 
proach  to  it  has  been  made.  In  fact,  in  the  midst  of  the 
immense  progress  which  medicine  has  made  in  its  positive 
truths,  and  the  great  revolutions  which  it  has  undergone  in  its 
theories,  we  have  not  erased,  in  this  new  edition,  anything 
essential  of  what  the  first  contained,  which  was  published  in 
1817,  twenty-three  years  ago.  If,  however,  but  little  of  the 
former  has  been  suppressed,  we  have  been  obliged  to  make, 
in  this,  the  third  edition,  numerous  and  important  additions. 
Wilhin  the  lapse  of  twenty-three  years,  auscultation  has  been 
discovered;  percussion,  perfected  in  its  manoeuvres,  has  been 
extended  in  its  applications;  the  observation  of  pathological 
phenomena  during  life,  and  the  study  of  anatomical  lesions  after 
death,  have  been  brought  to  a  degree  of  precision,  which,  previ- 
ously, they  did  not  possess,  and  have  furnished  us  with  many 
new  facts ;  chemistry  and  the  microscope  have  lent  their  aid 
to  pathology;  most  positive  consequences  have  been  deduced 
from  the  comparison  and  enumeration  of  better  observed  facts ; 
diagnosis  has  become  more  exact,  and  experiment  more  rigor- 
ous. We  have  sought,  in  this  new  edition,  to  omit  nothing  of 
whatever  important  conquests  have  been  made  by  science  :  this 
has  been  a  long  and  difficult  task,  in  the  midst  of  the  duties  of 
medical  teaching  and  the  demands  of  practice.  Thus,  even 
with  the  assistance  of  two  young  and  highly  distinguished 
physicians,  MM.  Dalmas  and  Grisolle,  who  have  kindly  made, 
in  the  works  recently  published,  the  necessary  researches  for  the 


XI 

present  volume,  six  years  have  elapsed,  from  the  time  when  the 
preceding  edition  was  exhausted,  to  the  publication  of  the 
present  one. 

This  new  edition  is  far  more  extended  than  the  second.  The 
chapters  devoted  to  the  causes,  the  symptoms,  and  the  progress 
of  diseases,  have  been  subjected  to  important  modifications,  and 
have  received  considerable  additions.  We  have  given  to  the 
chapter  on  Diagnosis  a  new  form  and  very  great  development : 
the  part  relating  to  therapeutics  has  been  greatly  augmented ; 
and  we  would  particularly  mention  two  articles,  —  one,  devoted 
to  the  exposition  of  the  rules  of  experiment  in  medicine ;  and 
the  other,  to  the  examination  of  a  question  sharply  contested,  — 
the  application  of  the  numerical  method  to  pathological  facts. 

PARIS,  OCTOBER  21,  1840. 


CONTENTS. 


CHAPTER  I. 

PATHOLOGY,  ITS  IMPORTANCE,  EXTENT,  AND  DIVISIONS.  GENERAL  PATHOL- 
OGY, ITS  EXTENT  AND  LIMITS  ;  THE  ADVANTAGES  AND  DANGERS  ATTEND- 
ING ITS  STUDY  J  MODE  OF  ITS  EXPLICATION  ...'.. 


CHAPTER  II. 

GENERAL   AND   SPECIAL   DEFINITIONS    OF   DISEASE 


CHAPTER  III. 

NOMENCLATURE    OF   DISEASES.  —  SYNONYMY.  —  ETYMOLOGY 


.     13 


CHAPTER  IV. 


SEAT   OF   DISEASES 


16 


CHAPTER  V. 


ETIOLOGY,   OR    THE   CAUSES    OF   DISEASE 

ARTICLE  I. 

Determining  causes           .         .  21 

Common  determining  causes  21 

Circumfusa            ...  22 

Applicata      ....  23 

Excreta,  gesta,  percepta        .  24 

Specific  determining  causes  25 

Common  specific  causes          .  25 

Metallic  emanations        .        .  25 

Miasmatic  exhalations            .  25 

Poisons          .          ...  26 
Contagious  specific  causes  or  virus  26 

ARTICLE   II. 

Predisposing  causes 


SECTION    I. 

General  predisposing  causes 
Atmosphere 
Winds        . 
Atmospheric  pressure 
Light         .... 
Electricity 

Seasons      .... 
b 


31 

32 
32 
32 
33 
33 
33 
33 


19 

Planetary  influences  .        .     34 

Localities  .        .        .        .34 

Garments  .        .         .         .36 

Food 36 

Moral  affections         .        .         .36 
Political  institutions  .        .     36 

SECTION     II. 

Individual  predisposing  causes     .     36 

1.  Aptitudes          .        .        .        .37 

A.  Origin          ....     37 

B.  Age 39 

C.  Climacteric  years         .        .40 

D.  Sex 41 

E.  Temperament      .        .        .41 

F.  Constitution         .        .        .    42 

G.  Habits          .        .        .        .42 
H.  Occupation  .        .        .43 
I.     Affluence  and  poverty          .    43 
J.    Healthy,  convalescent  or  dis- 
eased condition       .        .        .43 

K.   Pregnancy  .         .         .44 

2.  Individual   predisposing  causes 

proper 44 


XIV 


CONTENTS. 


A.  Circumfusa  (dissect'g  rooms, 
hospitals,  change  of  climate)       44 

B.  Applicata  (clothing,  various 
causes  of  compression,  beds, 
baths) 45 

C.  Ingesta  (food,  drinks,  spices, 
condiments,  medicaments)      .     48 

D.  Excreta  (evacuations)          .     50 

E.  Gesta  (exercise,  repose,  fa- 
tigue, want  of  exercise,  watch- 
ing, sleep)       .        .        .        .51 

F.  Percepta    (sensations,     pas- 
sions, mental  exertion,  ante- 
cedent diseases)      .        .        .52 

ARTICLE  III. 
Occasional  or  exciting  causes        .    53 

ARTICLE  IV. 

Mode  of  action  of  the  different  mor- 
bific causes  .     55 


Determining  causes           .  .     55 

Aptitudes           .        .         .  .57 

Predisposing  causes  proper  .     58 

Occasional  causes      .        .  .63 

ARTICLE  V. 

Division  of  diseases  relatively  to 

their  productive  causes  .  .     64 

Innate  or  congenital  diseases  .     64 

Acquired  diseases      .         .  .64 

Sporadic  diseases       .        .  .64 

Pandemic  diseases      .        .  .64 

Endemic  diseases       .        .  .64 

Epidemic  diseases      .        .  .65 

Essential  diseases      .        .  .69 

Symptomatic  diseases        .  .     69 

ARTICLE  VI. 

Lapse  of  time  between  the  applica- 
tion of  the  causes  and  the  de- 
velopment of  diseases  .  .  69 


CHAPTER  VI. 

PRECURSORY    PHENOMENA,    PRELUDES,    ANTECEDENT    SIGNS,    PRODROMES, 
IMMINENCE    OF    DISEASES 


OR 


70 


CHAPTER  VII. 


SYMPTOMS   OR   SYMPTOMATOLOGY 

ARTICLE  I. 

Symptoms  furnished  by  the  func- 
tions of  relation      .        .        .75 

SECTION   I. 

Symptoms  furnished  by  the  exter- 

na  appearance       .        .  .75 

A.  Attitude      .        .        .  .75 

B.  Volume  of  the  body     .  .    76 

C.  Growth  of  the  body     .  .     77 

D.  Firmness  of  the  flesh  .     78 

E.  Color  of  the  skin          .  .     78 

F.  Eruptions     .        .        .  .80 

G.  Plicatures     .        .        .  .80 
H.  Tumors,     excoriations,  fis- 
sures,  ulcers,  fistula     .  .     80 

Symptoms  furnished  by  the  head   .  81 
Symptoms  furnished  by  the  neck    .  90 
Symptoms  furnished  by  the  chest  .  91 
Symptoms  furnished  by  the  shoul- 
ders          91 

Symptoms  furnished  by  the  abdo- 
men          92 

Symptoms  furnished  by  the  organs 

of  generation          .        .        .94 

Symptoms  furnished  by  the  limbs  95 

SECTION    II. 

Symptoms  furnished  by  the  organs 

of  locomotion          .        •        .97 
Bones        ....         ,97 


Muscles,  (paralysis,  tremor,  ri- 
gidity, subsultus,  carphology, 
convulsions,  contraction,  etc.) 


SECTION    III. 


98 


Symptoms  furnished  by  the  voice 

and  speech     ....  102 

SECTION    IV. 

Derangements  of  sensibility  and  of 
sensation  considered  as  symp- 
toms   104 

Internal  sensations  (pain)  .  105 

External  sensations   .        .         .108 

A.  Sight        .         .        .        .108 

B.  Hearing  .         .        .        .109 

C.  Smell        .         .        .        .109 

D.  Taste        .        .        .        .109 

E.  Touch      .        .        .        .109 

SECTION    V. 

Symptoms  furnished  by  the  affec- 
tive functions  .  110 


SECTION    VI. 

Symptoms  furnished  by  the  intel- 
lectual functions  (delirium)     . 


Ill 


SECTION     VII. 

Symptoms  furnished  by  sleep 
(sleeplessness,  dreams,  som- 
nolency, coma,  etc.)  .  .113 


CONTENTS. 


XV 


SECTION    VIII. 

Lipothymia,  syncope,  vertigo        .  115 

ARTICLE   II. 

Symptoms  furnished  by  the  inter- 
nal or  assimilative  functions       116 

SECTION    I. 

Symptoms  furnished  by  digestion     117 

A.  Hunger       ....  117 

B.  Thirst         .         .         .         .118 

C.  Examination  of  the  various 
parts  of  the  mouth         .         .118 

The  teeth    .         .  .  .118 

The  gums   .         .  •  .119 

The  tongue          .  .  .119 

D.  Mastication           .  .  .123 

E.  Deglutition           .  .  .  123 

F.  Stomachal  digestion  .  .  125 

1.  Nausea      ....  125 

2.  Subsultus  praecordiorum     .   125 

3.  Regurgitation    .         .         .125 

4.  Vomiting  ....  126 

5.  Pain  .         .         .         .127 
Symptoms  furnished  by  the  intes- 
tinal canal          .         .         .  128 

1.  Borborygmi       .         .         .   128 

2.  Gurgling  .         .         .         .128 

3.  Passage  of  alimentary  sub- 
stances      ....  129 

4.  Alvine  excretion  or  defeca- 
tion   129 

5.  Excreted  substances  or  ex- 
crements   .         .         .         '131 

SECTION    II. 

Symptoms  furnished  by  the  respi- 
ration        .         .         .         .134 
1.  Frequency         .         .         .134 
2  Quickness          .         .         .135 

3.  Quantity  of  air  inspired  and 
expired      .         .         .         .135 

4.  Difficulty  of  respiration      .   135 

5.  Inequalities  of  respiration      136 

6.  Concomitant  sounds   .         .   136 

7.  Qualities  of  the  expired  air  137 

8.  Auscultation      .         .         .  137 
Modifications  of  the  respira- 
tory murmur  .         .  140 

Rales         .         .         .  .140 

Metallic  tinkling         .  .  145 

Thoracic  succussion    .  .  146 

Pleuritic  friction  sound  .  147 

Auscultation  of  the  voice  .  148 

Bronchophony  .         .  .  148 

.i'Egophony         .         .  .  149 

Pectoriloquy  •     .         .  .   150 

Percussion  of  the  chest  .  151 

§11.  Respiratory  phenomena  .   152 

1.  Laughter  ....  152 

2.  Yawning  .         .         .  .152 

3.  Sneezing   ....   152 


4.  Hiccough  . 

5.  Cough 
Exspuition 
Expectoration 
Sputa 


152 
152 
154 
154 
155 


SECTION    III. 


Symptoms  derived  from  the  circu- 
lation     162 

&  I.  Circulation  of  the  blood          .  163 

A.  The  heart   .         .         .         .163 

1.  Extent  of  the  heart's  pul- 
sations      ....   164 

2.  Shock  or  impulse       .         .  165 

3.  Nature  and  intensity  of  the 
sound         .         .         .         .166 

4.  Rhythm     .         .         .         .169 

B.  The  Pulse  .         .         .         .  170 
Auscultation  of  the  arteries     179 

C.  Symptoms  furnished  by  the 
capillary  circulation       .         .  180 

D.  Symptoms  furnished  by  the 
venous  circulation  .         .  181 

E.  Symptoms  furnished  by  the 
examination  of  the  blood        .  182 

§  II.  Symptoms  furnished  by  the 

lymphatic  system  .         .  189 

SECTION    IV. 

Symptoms  furnished  by  the  heat  .  192 
SECTION  v. 

Symptoms  furnished  by   the  ex- 
halations and  secretions  .   195 
§  1.  Exhalations  .         .         .  .196 

A.  Natural  exhalations      .  .   196 

1.  Cutaneous    exhalation,    or 
perspiration        .         .         .196 

2.  Mucous  exhalation     .         .   198 

3.  Serous  exhalation       .         .   199 

4.  Exhalations  upon  the  artic- 
ular surfaces       .         .         .  199 

5.  Exhalations  within  the  eye, 
the  ear,  the  adipose  cells, 
the  lymphatic  and  sanguine- 
ous system,  etc.          .         .  200 

7.  Gaseous  exhalation    .         .  200 

8.  Sanguineous  exhalation      .  200 

B.  Morbid  exhalations        .         .  200 

1.  Haemorrhage      .         .         .  200 

2.  Pyogenia  ....  201 
Pus  considered  in  regard  to 

its  chemical  properties 
and  its  action  upon  the 
animal  economy  .  .  204 

C.  Artificial  exhalations    .         .  206 
§  II.  Secretions,  properly  so  called  206 

1.  Secretion  of  tears  and  the 
fluid  of  the  meibomian  folli- 
cles   207 

2.  Secretion  of  the  saliva       .  207 

3.  Secretion  of  the  bile  .  208 


XVI 


CONTENTS. 


4.  Secretion  of  the  pancreatic 
juice          .         •         .         .210 

5.  Secretion  of  the  urine         .  210 
Physical  and  chemical  prop- 
erties of  the  urine          .212 

§  III.  Excretions          .         .         .219 

SECTION    VI. 

Symptoms  furnished  by  absorption  220 


SECTION   VII. 


Symptoms  furnished  by  nutrition  . 
Augmentation  (hypertrophy) 
Diminution  (atrophy)  . 


222 
222 
222 


ARTICLE  III. 

Symptoms  furnished  by  the  gen- 
erative functions    .         .         .223 

A.  In  the  male          .         .         .224 

B.  In  the  female       .         .         .224 

ARTICLE  IV. 

Symptoms  considered  in  disease    .  226 
Local  and  general  symptoms      .  227 
Sympathetic  phenomena ;  sym- 
pathies          ....  227 
Principal  and  accessory  symp- 
toms      228 

Active  and  passive  symptoms    .  229 
Epiphenomena  .         .         .  229 


CHAPTER  VIII. 

THE   PROGRESS   OR    COURSE   OP  DISEASES 


Types 231 

Acute  and  chronic  course          .  233 
Periods  in  diseases    .         .         .  233 

Invasion 234 

Period  of  stasis  or  violence        .  235 
Period  of  decline       .  .  235 


.  230 


Circumstances  which  modify  the 
course  of  diseases  (ages,  tem- 
perament diurnal  revolutions, 
temperature,  planetary  influ- 
ences, climate,  etc.) 


236 


DURATION    OF   DISEASES 


CHAPTER  IX. 


.  240 


TERMINATION   OF  DISEASES 


CHAPTER    X. 


ARTICLE  I. 

Different  modes  of  termination      .  242 
In  the  return  to  health      .         .  242 

In  death 244 

In  another  disease     .         .         .  245 
Doctrine  of  crises      .         .         .  246 
Seat  of  critical  phenomena        .  247 
Precursory  signs  of  critical  phe- 
nomena        .        .  .  249 


242 

Circumstances  which    favor  or 

oppose  critical  phenomena      .  252 
Duration  of  critical  phenomena    252 
Influence  of  critical  phenomena 
upon  the  termination  of  dis- 
eases   ,  .  253 


ARTICLE   II. 
Doctrine  of  critical  days 


256 


CHAPTER  XI. 


CONVALESCENCE 


259 


CHAPTER   XII, 


CONSECUTIVE   PHENOMENA 


262 


COiNTENTS. 


XV11 


CHAPTER  XITI. 


RELAPSE   AND   RECURRENCE 


.  264 


CHAPTER  XIV. 

THE   DIFFERENT   GENERA,    SPECIES   AND   VARIETIES   OF   DISEASES      . 


.  266 


CHAPTER   XV. 


COMPLICATIONS 


270 


CHAPTER  XVI. 


DIAGNOSIS 


273 


I.  Diagnostic  signs   .         .         .  273 

II.  Necessary  conditions  on  the 
part   of  the  patient  and  the 
physician  in  forming  a  diag- 
nosis      275 

Different  modes  of  exploration 

for  forming  diagnosis          .  276 

1.  Pressure    ....  276 

2.  Palpation  .  .  278 

3.  Touch       .         .  .280 

4.  Succussion         .  .  282 

5.  Mensuration       .  .  283 

6.  Percussion          .  .  286 

7.  Auscultation      .         .         .  290 

8.  Exploration  by  sounds  and 
probes        ....  293 

9.  Exploration  by  specula       .  294 

10.  Examinations  with  the  mi- 
croscope and  the  magnify- 
ing glass   ....  297 

11.  Employment    of   chemical 
agents  in  the  diagnosis  of 
disease      ....  297 

III.  Mode  of   examination  and 
interrogation  of    patients   for 
the  purpose  of  forming  a  diag- 
nosis      298 

Order  to  be  observed  in  ques- 
tioning patients      .         .         .  301 
Examination    of    the    existing 

symptoms  ....  302 
Exploration  of  the  head  .  .  303 
Exploration  of  the  spine  .  .  303 
Exploration  of  the  auditory  canal  304 
Exploration  of  the  nasal  fossae  .  304 
Exploration  of  the  isthmus  of 
the  fauces,  the  larynx  and  the 
ffisophagus  ....  305 
Exploration  of  the  chest  .  .  306 
Exploration  of  the  abdomen  .  308 
Exploration  of  the  genital  organs  309 


Exploration  of  the  rectum         .310 
Exploration  of  the  limbs  .         .310 
IV.    Principal    component    ele- 
ments of  diagnosis     .         .311 

A.  Determination  of  the  seat  of 

diseases     .         .         .         .312 

1.  Which  is  the  affected  organ?  312 

2.  The  seat  of  disease  being 
known,  what  is  its  extent?    314 

3.  Which   of  the   elementary 
tissues  is  primarily  affected  ?  3 1 5 

B.  Determination  of  the  lesion      316 
1.  Nature  of  the  lesion  . 


317 
318 


2.  Degree  attained  by  the  le- 
sion   

C.  Symptomatic  phenomena  con- 
sidered in  regard  to  diag- 
nosis .  .  .  .319 
§  V.  Circumstances  which  may 
render  diagnosis  difficult  and 
even  uncertain  .  .  .  321 

1.  Difficult   diagnosis    on    ac- 
count of  the  period  at  which 
the  physician  is  summoned    321 

2.  Difficulties  in  diagnosis  de- 
pending upon  the  predomi- 
nance of  general   phenom- 
ena,  or    the    obscurity   or 
absence  of  local  phenomena  323 

The  febrile  state  in  relation 
to  diagnosis    .         .         .  330 

3.  Difficulties  in  diagnosis  re- 
sulting from  the  infrequency 

of  the  disease    .         .         .336 

4.  Difficulties   resulting    from 
complications      .         .         .  337 

5.  Difficulties  resulting    from 

deception        .         .         .  338 
Feigned  and  concealed  dis- 

.  338 


XV111 


CONTENTS. 


CHAPTER  XVII. 


PROGNOSIS 


I.  Conditions  on  the  part  of  the 
patient  and  the  physician  for  the 
formation  of  the  prognosis          .  341 

II.  Prognostic  signs  .         .  342 

1.  Diagnosis  the  original  basis 

of  prognosis  .         .         .  343 

2.  Power  of  nature  and  of  art    344 

3.  Age,  previous  health,  phys- 

ical and  moral  causes  .  344 
Hereditary  condition  .  345 
Menstruation,  pregnancy, 

the  puerperal  state  .  345 
Habitual  intemperance  .  345 
Excessive  evacuations  —  fa- 

tigue .  .  .  .346 
Climate  —  seasons  .  .  346 

4.  Precursory  phenomena       .  346 


341 

5.  Commencement  of  diseases  346 

6.  Progress  of  diseases  .         .  347 

7.  Duration  of  diseases  .  347 

8.  Influence  of  remedies  pre- 

viously employed    .         .  347 

9.  Complications    .         .         .  347 
Prognostic  value  of  certain 

symptoms  considered  sep- 
arately (external  appear- 
ance, aphonia,  pain,  sen- 
sorial  disturbance,  deli- 
rium, sleep,  dysphagia, 
hunger,  thirst,  meteor- 
ism,  involuntary  evacua- 
tions, stertorous  respira- 
tion, syncope,  sweats, 
haemorrhage,  parotiditis)  348 


CHAPTER  XVIII. 

THE    DIFFERENT    ALTERATIONS    PRESENTED    BY  THE    ORGANS    AFTER  DEATH 


ARTICLE  I. 
Mode  of  conducting  post-mortem 

examinations          .         .         .  358 

Examination  of  the  exterior  of 
the  body        .         .         .         .358 

Inspection  of  the  internal  organs  359 

Mode    of    opening    the    great 
splanchnic  cavities         .         .  360 

Order  in  which  visceral  inspec- 
tion should  be  conducted        .  361 

ARTICLE  II. 
The  principal  lesions  presented  by 

the  organs  after  death   .         .365 

FIRST    SERIES. 

Lesions  of  the  solids     .        .         .  365 
Inflammation  of  the  various  tis- 
sues       366 

Ulcers 367 

Fistula 368 

Gangrene          ....  368 
Tubercle  ....  368 

Granulations     .         .         .         .369 
Cancer     .         .  .  370 


357 

Scirrhus 370 

Melanosis          ....  371 

Cutaneous  transformation  .  372 

Mucous  transformation       .  *  .  372 

Serous  transformation        .  .  372 

Fatty  transformation          .  .  372 

Fibrous  transformation      .  .  373 

Oseous  transformation        .  .  373 

Cartilaginous  transformation  .  373 

Corneous  transformation  .  .  373 

Alterations  of  form    .         .  ,  373 

Alterations  of  volume        .  .  373 

Alterations  of  color  .         .  .  373 

SECOND   SERIES. 

Alterations  of  the  fluids  .  .  374 
Alterations  of  the  liquids  .  .  374 
Alterations  of  the  gases  .  .  377 

THIRD   SERIES. 

Foreign  bodies,  inanimate  and  liv- 
ing   378 

Different  importance  of  cadaveric 
changes  .....  379 


CHAPTER  XIX. 


THERAPEUTICS 


Observation  and  experience  the 
only  guides  in  the  study  of 
therapeutics  .  .  .  381 
Experimentation,  its  difficulties, 
the  requisite  rules  in  its  pur- 
suit   383 


380 

The  numerical  method  applied 
to  the  study  of  diseases  .  393 

Refutation  of  the  principal  ob- 
jections to  the  numerical  sys- 
tem .  .  .  .  .395 

Experience  in  medicine     .         .  403 


CONTENTS. 


XIX 


Physical  and  chemical  theories 
applied  to  therapeutics  .         .  405 

ARTICLE  I. 

Indications 406 

Conditions  productive  of  indica- 
tions      406 

A.  Genus  of  the  disease          .  406 

B.  Character  of  the  disease     .  407 

C.  Type  of  the  disease    .         .  407 

D.  State  of  the  vital  forces       .  408 

E.  Intensity  of  the  disease        .412 

F.  Different  periods  of  the  dis- 
ease       412 

G.  Particular  symptoms  .413 
H.  Seat  of  diseases          .  .414 
I.  Complications     .         .  .414 
J.  Causes        .         .         .  .414 

Temperament,  constitution, 
age,  sex,  profession,  hab- 
itual regimen  .  .  .415 

K.  Commemorative  circumstan- 
ces   416 

L.   Means  previously  employed  418 


M.   Epidemic  constitution          .  419 
N.   Tendency  of  the  disease      .419 
O.   Influence  exercised  by  the 
disease  upon  the  constitu- 
tion   420 

Possibility  of  the  occurrence 
of  several  indications  in  one 
and  the  same  disease         .  420 
Preservative  indications          .  422 
Principal  indications  in  con- 
valescence         .         .         .  423 
Indications  furnished  by  the 
consecutive  phenomena      .  423 

ARTICLE  II. 

Therapeutical  means   .        .  .  423 
Therapeutical  means,  properly 

so  termed  .         .  .424 

Surgical  means     .         .  .  424 

Medical  means       .         .  .  425 

General  or  hygienic  means  .  428 

Means  in  acute  diseases  .  429 

Means  in  chronic  diseases  .  434 


CHAPTER  XX. 

NATURE  OR  ESSENCE  OF  DISEASES 

Ideas  of  the  humoral  pathologists 
Ideas  of  the  Solidists 


435 

437 

438 


CHAPTER   XXI. 


CLASSIFICATION    OF    DISEASES 


442 


CHAPTER  XXII. 

PRINCIPAL    WORKS    UPON    GENERAL    PATHOLOGY 


444 


INDEX 


451 


ERRATA. 


Page  80,  lines  19  and  23,  for  "  vesicula,"  read  vesiculce. 

"  10J,  line  16,  insert  a  comma  after  "attacks." 

"  115,  lines  11  and  32,  for  "  Topor,"  read  Sopor. 

"  117,  line  21,  for  "boulimus,"  read  boulimia. 

"  117,  lines  24  and  26,  dele  the  parentheses. 

"  128,  line  25,  for  "  sound,"  read  sounds. 

"  136,  note,  for  ntvw,  read  nvt<a. 

"  182,  line  35,  for  "  Nosographic,"  read  Nosographie. 

"  186,  line  13  from  bottom,  for  "secretions,"  read  secretion. 

"  189,  line  20,  for  "  Seltzar,"  read  Seltzer. 

"  189,  line  4  from  bottom,  for  §  I.  read  §  II. 

"  197,  line  30,  for  "  mouldiness,"  read  mould. 

"  200,  line  5  from  bottom,  for  "  haemorrhages  consist,"  read  haemorrhage  consists. 

"  208,  line  7  from  bottom,  for  "  after,"  read  of  the. 

11  213,  line  30,  for  "  a  thousandth,"  read  of  a  thousandth. 

"  226,  line  14,  for  "  venereus,"  read  venereus. 

"  229,  last  line,  for  "  epigenometa,"  read  epigenemeta. 

"  231,  note,  for  i//v£«£oe,  read  7ivQ(£ig. 

"  300,  line  3  from  bottom,  for  "  diagnosing,"  read  diagnosticating. 


ELEMENTS 


OF 


GENERAL    PATHOLOGY 


CHAPTER  I. 

PATHOLOGY,     ITS     IMPORTANCE,      ITS     EXTENT,      AND     ITS      DIVISIONS.  

GENERAL     PATHOLOGY,    ITS     EXTENT,    ITS    LIMITS. ADVANTAGES    AND 

DANGERS    ARISING   FROM   ITS    STUDY. ORDER    ADOPTED   IN    ITS    EXPO- 
SITION. 

PATHOLOGY  has  been  defined  to  be  that  branch  of  medicine 
which  treats  of  the  classification,  causes,  symptoms  and  signs  of 
disease.  This  definition  is  far  from  accurate.  As  it  is  the  pecu- 
liar province  of  physiology  to  treat  of  whatever  relates  to  the 
human  body  in  its  normal  condition,  so  pathology  includes  within 
its  limits  whatever  relates  to  the  same  in  a  state  of  disease.  The 
seat  of  diseases,  the  phenomena  which  precede  and  follow  them, 
their  progress,  duration  and  different  modes  of  termination,  their 
reappearance,  various  forms  and  complications,  the  changes  they 
produce  in  the  texture  of  organs,  their  prophylactic  and  curative 
treatment,  &c.  &c.,  are  but  so  many  essential  points  in  their  his- 
tory, which  necessarily  fall  within  the  cognizance  of  pathology,* 
or  that  branch  of  medical  science,  the  object  of  which  is  the  know- 
ledge of  disease. 

Of  the  various  branches  of  the  healing  art,  none  to  the  physician 
is  so  attractive  as  a  study,  none  so  important  in  its  results,  as 
pathology.  He  views  it  as  a  centre,  around  which  are  disposed  at 
unequal  distances  the  other  natural  sciences.  The  study  of  anat- 
omy and  physiology,  of  chemistry  and  physics,  of  botany  and 

*  n«6og,  disease;  loyog,  discourse. 
1 


2  GENERAL    PATHOLOGY. 

materia  medica,  afford  him  but  an  introduction  to  that  of  pathol- 
ogy ;  he  regarding  those  sciences  of  far  less  importance,  so  soon  as 
the  latter  shall  become  the  object  of  his  special  study,  viewing 
them  rather  as  accessory  sciences,  and  among  the  numerous  facts 
presented  by  them,  noting  only  those  which  are  nearly  connected 
with  the  knowledge  of  disease,  and  its  appropriate  methods  of 
treatment. 

We  would  not  however  exalt  the  science  of  pathology  at  the 
expense  of  the  other  branches  of  natural  history ;  whatever  be  its 
importance,  and  the  dignity  of  its  aim,  we  claim  for  it  no  supe- 
riority over  the  other  sciences.  Physiology,  physics,  zoology,  &c., 
it  will  not  be  denied,  are  entitled  to  equal  consideration.  Inti- 
mately connected  as  are  all  these  sciences,  they  reciprocally  aid  in 
the  elucidation  of  each  other,  and  none  among  them  should  be 
allowed  the  preeminence,  although  in  his  estimation  who  makes  it 
his  particular  study,  either  will  appear  of  paramount  importance. 

Pathology,  like  the  other  natural  sciences,  is  without  limit ;  while 
botany,  zoology,  physics,  chemistry  and  mineralogy  are  daily  ex- 
tending their  domain,  the  science  of  disease,  also,  to  the  observer, 
appears  to  be  rapidly  advancing.  Without  here  referring  to  the 
ever  new  and  infinite  varieties  of  disease,  this  must  be  evident, 
whether  we  consider  the  more  careful  study  of  causes,  the  more 
accurate  description  of  symptoms,  the  more  critical  examination 
of  the  circumstances  which  exert  a  favorable  or  unfavorable  in- 
fluence upon  the  progress  of  diseases,  the  discovery  of  affections 
previously  unknown  or  imperfectly  described,  or  lastly,  the  appli- 
cation of  new  methods  of  exploration  to  the  phenomena  of  disease. 
To  cite  a  recent  example,  has  not  the  discovery  of  auscultation,  in 
our  own  time,  added  to  the  history  of  thoracic  disease,  a  multitude 
of  phenomena  and  valuable  diagnostic  signs,  of  which  we  were 
previously  ignorant  ?  Pathology  presents  for  consideration,  a  mass 
of  facts,  all  the  details  of  which  it  is  beyond  the  power  of  the 
human  mind  to  comprehend ;  it  may  even  be  asserted  that,  throw- 
ing aside  its  theories  and  its  systems,  no  one  is  possessed  of  all  the 
knowledge  contained  in  the  records  of  pathological  science. 

This  want  of  correspondence  between  the  extent  of  the  science 
and  the  capacity  of  the  human  mind,  has  led  to  results  which  were 
not  unforeseen.  It  being  impossible  to  increase  the  mental  powers, 
it  was  attempted  to  make  a  division  of  the  science  into  several 
parts  which  should  be  within  the  reach  of  our  intellectual  capacity. 
Hence  the  numerous  divisions  of  pathology.  Of  these  the  most 
important  is  that  distinctive  of  internal  or  medical,  and  external 
or  surgical  pathology.  The  diseases  of  women,  of  children,  of  the 
aged,  those  seated,  whether  in  any  of  the  splanchnic  cavities,  in 
any  of  the  great  anatomical  systems,  in  an  apparatus,  or  single 
organ,  &c.,  have  severally  undergone  subdivision;  and  eminent 
professional  men  have  deigned  to  devote  themselves  exclusively  to 
the  study  of  a  single  class  of  these  affections.  But  it  should  be 
recollected  that,  in  no  instance,  has  the  investigation  of  a  special 
group  of  diseases  been  of  profit  to  the  science,  except  so  far  as 


GENERAL    PATHOLOGY.  3 

those,  who  have  devoted  themselves  to  these  studies,  have  been 
well  versed  in  the  other  branches  of  pathology.  Diseases  are  not 
confined  in  their  effects  to  single  organs,  nor  can  they  be  discon- 
nectedly studied. 

There  is  another  division,  which  has  had  the  effect  to  enlarge 
rather  than  diminish  the  range  of  the  science,  and  which,  like  that 
adopted  by  Bichat  in  the  study  of  anatomy,  has  extended  its  lim- 
its. We  refer  to  the  division  into  general  and  descriptive  patholo- 
gy. The  object  of  this  is  not  to  divide  the  science  into  several 
parts,  nor  to  separate  a  particular  class  of  diseases  from  all  others. 
General  pathology,  whose  object  it  is  to  treat  of  diseases  in  the 
abstract,  and  of  whatever  is  common  to  them,  includes  all  under 
the  same  head,  studies  their  general  characteristics,  causes  and 
development,  the  succession  and  connection  of  their  phenomena 
observed  during  life,  the  appearances  after  death,  and  the  circum- 
stances which  modify  their  progress,  and  by  which  we  are  enabled 
to  prognosticate  the  changes  which  will  take  place  in  their  course. 
Descriptive  pathology  includes  alike  all  diseases,  but  presents 
them  in  a  series  of  groups,  in  which  each  affection  is  described, 
with  the  appearances  peculiar  to  it,  and  which  serve  to  distinguish 
it  from  all  others.  Hence,  it  is  evident  that  there  is  no  analogy 
between  this  division  of  the  subject,  and  those  before  mentioned. 
The  latter  shorten  the  study,  by  presenting  fewer  objects  for  in- 
vestigation ;  the  former  leads  to  the  same  result  without  narrowing 
the  limits  of  the  science ;  and  not  only  does  it  preserve  it  entire, 
but  by  presenting,  under  different  aspects,  the  objects  to  which  the 
attention  should  be  successively  directed,  we  obtain  a  more  accu- 
rate knowledge  and  a  more  just  appreciation  of  them. 

This  division  differs  also  from  the  first  in  other  respects.  It  is 
possible  to  devote  ourselves  exclusively  to  the  study  of  internal,  and 
neglect  to  a  certain  extent  that  of  external  pathology :  so  special 
study  may  be  made  of  those  diseases  which  occur  during  child- 
hood or  old  age,  while  those  peculiar  to  other  periods  of  life  are 
neglected.  General  and  special  pathology,  on  the  contrary,  cannot 
be  exclusively  studied ;  one  is  but  an  introduction  to  the  other ; 
both  are  indispensable  to  the  physician. 

This  division  of  pathology  is  one,  the  limits  of  which  are  the 
most  clearly  defined.  The  consideration  of  all  the  phenomena 
common  to  diseases  belongs  to  general  pathology,  while  whatever 
relates  to  the  history  of  particular  diseases  falls  within  the  prov- 
ince of  descriptive  pathology.  Between  these  two  branches  of 
pathology,  there  are  however  numeroiis  points  of  contact ;  but  it 
is  not  a  little  singular  that  most  authors  who  have  treated  upon 
general  pathology,  should  have  introduced,  among  considerations 
legitimately  within  the  province  of  that  subject,  the  history  of 
particular  diseases.  Thus  the  description  of  plethora  is  found  in 
almost  all  treatises  upon  general  pathology.  Sprengel,  in  his 
valuable  work  *  upon  this  subject,  goes  still  farther,  and  treats 

*  Pathologia  Generalis.    Amstelodami,  1813. 


GENERAL  PATHOLOGY. 


successively  (in  the  article,  Etiology,)  of  the  signs  of  the  various 
fractures,  dislocations,  and  hernise,  and  describes  the  various  kinds 
of  worms  which  infest  the  human  body,  with  the  signs  indicative 
of  their  presence.  While  subjects  are  thus  considered  in  connec- 
tion with  general  pathology,  which  are  not  within  its  scope,  others 
strictly  belonging  to  it  are  neglected.  The  nomenclature  of  dis- 
eases, the  circumstances  which  influence  their  course,  the  treat- 
ment, convalescence,  and  appearances  after  death,  the  mode  of 
examination  and  interrogation  of  patients,  are  all  important  points 
in  the  general  history  of  diseases,  which  authors  have  hitherto 
omitted  to  mention,  although  as  essential  to  it  as  the  classification, 
causes,  symptoms  and  signs. 

If  the  division  of  pathology  into  general  and  descriptive,  appear 
to  some  rather  to  prolong  than  to  abridge  the  study  of  diseases,  it 
will  be  an  easy  task  to  bring  them  to  a  more  just  conclusion.  We 
readily  grant  that  the  knowledge  of  particular  diseases  is  of  the 
highest  importance,  and  that  the  study  of  general  pathology  is  not 
of  equal  utility  to  the  practical  physician.  But  admitting  for  a 
moment,  that  the  latter  be  wholly  valueless  to  him  who  is  already 
versed  in  science,  it  would  not  be  therefore  just  to  conclude  that  it 
is  without  profit  to  the  student.  Without  here  referring  to  the  ab- 
solute necessity  of  his  first  becoming  familiar  with  a  new  language, 
the  study  of  general  pathology  is  to  him  in  other  respects  of  man- 
ifest utility ;  all  is  as  yet  new  to  him,  he  should  leave  no  point 
unattained.  Diseases  possess  certain  forms  in  common,  they  have 
also  features  which  are  peculiar  to  them.  Were  it  not  better,  we 
would  then  ask,  to  present  to  the  beginner,  once  for  all,  the  vari- 
ous points  of  doctrine,  and  the  phenomena  common  to  most  dis- 
eases, and  thereby  avoid  the  necessity  of  afterward  pointing  out 
those  peculiar  to  each,  than  to  weary  him  with  tedious  and  unpro- 
fitable repetitions,  which,  in  the  description  of  each  particular  dis- 
ease, must  necessarily  lead  to  an  incomplete  examination  of  the 
same  questions  ?  In  short,  should  he  be  made  acquainted  at  once 
with  the  characteristics  common  to  all  diseases,  or  be  under  the 
necessity  of  reviewing  the  same,  as  often  as  he  should  be  led  to 
the  investigation  of  a  particular  disease  ?  The  answer  is  evident. 

There  are  still  numerous  other  advantages  attending  the  study 
of  general  pathology.  It  gives  scope  to  considerations,  favorable  to 
the  development  of  the  understanding,  and  an  enlargement  of  the 
views  of  the  student.  It  briefly  points  out  to  him,  at  the  com- 
mencement of  his  career,  the  path  he  should  pursue,  the  objects 
which  claim  his  attention,  and  the  dangers  to  be  avoided ;  it  also 
indicates  the  course  which  should  be  adopted  in  the  investigation 
of  particular  diseases ;  and  lastly,  by  grouping  together  these  va- 
rious affections,  it  aids  in  the  elucidation  of  their  history. 

But  aside  from  the  advantages,  there  are  dangers  connected 
with  the  study  of  general  pathology.  A  cursory  examination  of 
the  treatises,  upon  this  subject  will  alone  suffice,  to  show  us  the 
systems  and  hypotheses,  which  have  been  either  substituted  for,  or 
mingled  with,  the  results  of  observation  or  experience.  The  same 


GENERAL    PATHOLOGY.  5 

may  be  said,  it  is  true,  of  most  medical  treatises,  whatever  be 
their  object,  as  descriptions  of  particular  diseases,  and  even  records 
of  observations.  But  systems  properly  so  called,  those  great 
hypotheses,  by  which  the  universality  of  facts  is  understood  and 
explained,  necessarily  proceed  from  general  pathology.  The  com- 
parison of  diseases,  the  study  and  comparison  of  their  various 
phenomena,  necessarily  lead  to  those  general  conclusions  so 
seductive  to  the  mind,  which  receives  them  with  dangerous 
facility,  proudly  proclaiming  them  as  secrets  wrested  from  nature, 
as  laws  without  exception ;  and  should  they  afterward  be  shown 
by  facts  to  be  inaccurate  or  false,  to  nature  rather  than  to  the 
theory  is  the  error  ascribed ;  the  freaks  and  caprices  of  nature 
excite  astonishment,  while  the  theory  is  still  regarded  with  admi- 
ration, until  some  other  takes  its  place,  which  ultimately  shares 
the  same  fate.  When  it  is  considered  that  general  pathology  treats 
of  subjects  abstractly,  and  that  hence  it  becomes  easy  to  wander 
from  the  truth,  the  tendency  of  this  science  to  the  formation  of 
those  theories  by  which  the  progress  of  medicine  has  been  so 
long  impeded,  becomes  manifest. 

If  the  knowledge  of  the  dangers  be  sufficient  in  order  to  avoid 
them,  we  hope  that  we  ourselves  have  escaped  from  those  to 
which  we  have  just  alluded ;  but  whatever  may  have  been  our 
efforts  to  attain  this  end,  we  dare  not  flatter  ourselves  that  we  have 
succeeded.  Those  most  averse  to  theories  and  hypotheses,  have 
not  in  all  cases  been  able  to  guard  against  them ;  they  have  over- 
thrown the  hypotheses  of  others,  by  substituting  those  of  their 
own  invention,  and  which  appeared  to  them  but  the  legitimate 
results  of  observation  and  experience.  It  was  a  remark  of  Gaubius, 
that  it  is  better  to  pause,  than  go  blindly  forward ;  and  yet,  in 
the  same  work,  he  himself  becomes  enveloped  in  the  mists  of 
humorism,  and  gravely  descants  upon  the  chemical  and  mechani- 
cal acrimonies  of  the  humors. 

If,  as  we  have  seen,  the  province  of  general  .pathology  has  not 
been  with  certainty  determined,  and  it  be  necessary  to  strip  it  of 
the  erroneous  and  dangerous  theories  which  have  till  now  rendered 
it  obscure,  it  is  no  less  important  that  a  far  different  course  be 
adopted  in  its  exposition,  from  that  hitherto  pursued.  By  refer- 
ring, as  has  been  the  case,  to  nosology  or  the  classification  of  dis- 
eases, their  definition,  seat,  course,  duration  and  complications, 
subjects  are  considered  under  the  same  head,  which  should  be 
separately  studied,  and  which  are  as  widely  different  as  signs  and 
symptoms,  from  which  two  distinct  branches  have  arisen ;  if,  in 
connection  with  the  nosology,  the  seat,  progress  and  duration  of 
diseases,  which  have  but  a  vague  affinity  to  their  classifications, 
be  considered,  it  is  not  clear  why  on  this,  all  other  branches  of 
general  pathology  should  not  depend. 

Is  the  method  to  be  pursued  in  the  study  of  general  pathology 
an  important  consideration  ?     Is  it  absolutely  necessary,  for  exam- 
ple, in  our  inquiries,  that  prognosis  be  considered  before  diagnosis, 
or  the  causes  before  the  seat  of  disease  ?     We  think  not ;  but  are 
1* 


6  DEFINITION    OF    DISEASE. 

yet  of  the  opinion  that  there  are  certain  points  in  the  history  of 
diseases,  which,  before  others,  naturally  claim  our  first  attention. 
The  definition  of  disease,  is  the  first  subject  which  presents  itself; 
the  study  of  the  progress  of  diseases  should  not  precede  the 
exposition  of  the  symptoms,  and  the  causes  more  properly  come 
before  than  after  the  latter ;  the  diagnostic  and  prognostic  signs 
should  follow  the  symptoms,  and  the  consideration  of  the  treat- 
ment come  after  the  signs.  Thus  among  the  various  subjects  em- 
braced by  general  pathology,  there  are  those  whose  relative  posi- 
tion is  to  a  certain  extent  defined,  while  there  are  others  which 
may  be  considered  with  equal  propriety  at  different  periods  during 
the  investigation. 

In  the  arrangement  of  the  subjects  which  constitute  general 
pathology,  it  seems  to  us  important  that  some  method  be  adopted, 
which  shall  be  equally  applicable  to  the  study  of  particular  dis- 
eases. This  method  would  thus  become  more  strongly  impressed 
upon  the  mind.  It  is  moreover  well  known  that  a  uniform  method 
powerfully  assists  the  memory,  accustoming  the  mind  to  a  proper 
arrangement  of  its  ideas,  and  the  classification  of  the  new  truths 
which  are  daily  presented. 

The  following  is  the  order  we  have  adopted  in  the  exposition 
of  general  pathology. 

We  shall  first  consider  the  definition  of  disease  in  general,  and 
point  out  the  rules  which  should  guide  us  in  the  definition  of  dis- 
eases respectively.  After  some  considerations  on  the  nomenclature, 
etymology  and  synonomy,  we  shall  speak  of  the  seat  of  diseases, 
their  cames,  precursory  phenomena,  symptoms,  progress,  dura- 
tion and  various  terminations.  We  shall  thus  be  led  to  the  ex- 
amination of  the  doctrine  of  crises  and  critical  days.  Convales- 
cence, the  consecutive  phenomena,  relapse,  kinds,  varieties  and  com- 
plications of  diseases,  diagnosis  and  prognosis,  will  be  generally 
considered.  We  shall  also  devote  a  chapter  to  the  examination"  and 
appearances  of  bodies  after  death ;  and  having  touched  upon  the 
fundamental  rules  of  treatment,  we  shall  conclude  by  offering  a 
few  remarks  on  the  nature  and  classification  of  diseases.  —  O. 


CHAPTER  II. 

DEFINITION    OF   DISEASE     IN     GENERAL,    AND    OF    DISEASES     RESPECTIVELY. 

THERE  are  two  kinds  of  definition,  one  being  an  accurate  state- 
ment of  the  nature  of  a  thing,  the  other  a  rapid  enumeration  of 
its  principal  characteristics.  In  either  case,  the  definition  to  be 
correct,  should  present  so  clear  an  idea  of  the  object  defined,  as 
to  render  it  always  recognizable,  and  easily  distinguishable  from 
all  others. 


DEFINITION    OF   DISEASE.  7 

Of  these  two  kinds  of  definition,  the  first,  which  acquaints  us 
with  the  nature  of  things,  would  be  preferable  to  the  second,  were 
it  as  certain  and  general  in  its  application ;  but  there  is  a  vast 
number  of  objects  whose  nature  is  unknown  to  us ;  and  though 
there  be  those  in  which  it  seems  to  be  understood,  this  knowledge 
is  rarely  so  well  established,  as  to  serve  as  a  basis  whereon  to 
found  a  correct  definition.  The  second  mode  of  definition  con- 
sists rather  in  a  brief  description,  than  a  definition  of  the  object. 
It  rests  on  phenomena  appreciable  to  our  senses,  without  reference 
to  the  nature  of  the  object  itself,  which  is  beyond  their  reach,  and 
the  knowledge  of  which  can  only  be  attained  by  abstract  reason- 
ing. It  has  been  justly  remarked  by  M.  Dumas  that  abstractions 
mislead  the  mind,  while  truth  is  conveyed  to  us  through  the  medi- 
um of  our  senses.  The  history  of  all  sciences,  and  particularly 
that  of  medicine,  proves  the  truth  of  this  assertion.  During  the 
period  when  the  first  mode  of  definition  was  employed,  the  pro- 
gress of  science  was  retrograde ;  when,  on  the  contrary,  the 
description  came  to  be  substituted  for  the  definition,  its  advance 
was  constant. 

I.  Disease,  as  is  well  known,  is  that  state  opposed  to  health,  a 
word  the  significance  of  which  is  familiar  to  every  one.  But  to 
render  an  accurate  definition  is  still  no  less  difficult,  as  is  evident 
from  the  number  and  variety  of  those  which  have  been  already 
proposed.  Many  physicians  have  attempted  its  definition  by 
referring  to  its  nature,  or  its  ultimate  cause.  Alcmoeon  de  Crotone 
made  it  to  consist  in  a  derangement  of  the  forces,  the  concurrence 
and  harmonious  action  of  which  result  in  health ;  Plato,  in  his 
definition,  for  forces,  substituted  elements,  and  Asdepiades  replaced 
the  elements  of  Plato  by  indivisible  corpnscules  ;  Sylvius  viewed 
disease  as  a  reaction  of  salts ;  Broivn,  a  lesion  of  excitability ; 
Ritter,  a  galvanic  change ;  Baumes,  a  change  in  the  proportion  of 
caloric,  oxygen,  hydrogen,  nitrogen  and  phosphorus;  and  Broussais, 
an  effect  of  irritation,  &c.  Most  of  the  other  definitions  of  dis- 
ease, founded  upon  its  nature,  are  either  comprised  in  those  above 
cited,  or  are  so  obscure,  as  to  require  a  long  explanation  to  render 
them  intelligible  ;  they  have  consequently  been  omitted  in  a  work 
strictly  elementary,  and  in  which  such  a  display  of  erudition 
would  be  out  of  place.  Before  taking  leave  of  this  subject,  how- 
ever, due  consideration  should  be  given  to  the  definition  of  disease 
proposed  by  Sydenham. 

This  writer,  with  all  his  natural  sagacity  and  soundness  of 
judgment,  attempted  to  define  disease,  according  to  its  peculiar 
nature.  "  Dictat  ratio,  si  quid  ego  hie  judico"*  modestly  says 
this  eminent  physician,  "morbum  quantum  libet  ejus  causce  humano 
corpori  adversantur,  nihil  esse  aliud  quam  naturce  conamen 
matericB  morbificce  exterminationem,  in  ccgri  salutem,  omni  ope 
molientis."  This  definition,  although  approximating  in  some 
respects  to  the  present  language  of  the  science,  is  nearly  as  defec- 

*  Sydenham,  de  morbis  acutis  in  genere,  page  19. 


8  DEFINITION    OF   DISEASE. 

live  as  those  which  preceded  it,  presenting  but  a  vagne  idea  of 
an  indeterminate  effort  of  nature,  a  power  of  which  we  are  totally 
ignorant.  Besides,  the  effort  exerted  by  nature  to  destroy  the 
morbific  cause,  would  rather  constitute  the  remedy,  than  the  dis- 
ease. Finally,  this  reaction  against  the  morbific  cause  does  not 
always  exist,  and  consequently  Sydenham's  definition,  were  it 
correct  in  other  respects,  would  fail  in  this,  since  a  definition 
should  apply  to  all  cases. 

The  nature  of  disease  being  unknown,  it  becomes  necessary  to 
seek  other  grounds  upon  which  to  found  its  definition.  This 
necessity  has  been  recognized  by  pathologists  of  every  age. 
"  Disease  has  by  some  authors  been  defined  to  be  a  derangement 
of  the  functions.  To  this  it  has  been  objected  that  mere  function- 
al disturbance  is  insufficient  to  constitute  disease,  and  that  there 
are  certain  phenomena,  which  are  capable  of  giving  rise  to  the 
former,  without  producing  the  latter.  A  state  of  general  disturb- 
ance ordinarily  accompanies  the  catamenial  flow  in  females,  not 
however,  amounting  to  disease.  Parturition  is  attended  with 
violent  pains,  is  folio-wed  by  a  flow  of  blood,  together  with  a 
feeling  of  weariness  and  debility,  yet  without  the  existence  of 
disease.  A  violent  passion,  as  anger  or  fright,  may  give  rise  to 
extreme  functional  disturbance,  without  however  inducing  disease. 
In  old  age,  the  exercise  of  the  functions  no  longer  takes  place  with 
the  same  regularity ;  the  organs  of  generation  become  gradually 
unfitted  for  reproduction,  the  functions  of  relation  become  by  de- 
grees enfeebled,  the  intellectual  faculties  become  clouded,  the  sen- 
sations blunted,  and  the  step  unsteady.  The  organs  of  individual  * 
life  themselves  become  subsequently  affected,  yet  without  the 
existence  of  disease.  In  the  person  who  has  been  deprived  in  any- 
way of  an  eye  or  an  arm,  there  is  not  a  regular  exercise  of  all 
the  functions,  yet  it  is  manifest  that  disease  does  not  exist.  A 
sensation  of  uneasiness  in  any  part,  an  acute  but  momentary  pain, 
a  transient  spasm,  or  involuntary  movement,  are  instances  of 
functional  derangement,  but  cannot  be  considered  as  diseases. 

Disturbance  of  the  functions  alone  is  then  insufficient  to  constitute 
disease,  since  even  a  considerable  irregularity  in  their  performance 
is  not  necessarily  incompatible  with  health.  To  define  health 
therefore  to  be  that  state  in  which  all  the  functions  are  performed 
with  harmony  and  regularity,  is  incorrect.  There  is,  as  has  been 
said,  an  individual  health  which  is  influenced  by  a  variety  of  cir- 
cumstances. This  has  been  remarked  by  many  physicians,  and 
has  led  them  to  modify  the  definition  under  consideration.  Some 
have  said,  that  functional  derangement  to  constitute  disease  must 
be  the  result  of  morbific  causes.*  By  others,  the  epithet  preter- 
natural has  been  prefixed  to  signify  that  such  functional  disturbance 
must  be  a  deviation  from  the  ordinary  course  of  nature,  f  This  defi- 

*  Ludwig,  Patholog.  Instil.,  page  6. 

f  The  Latin  adjective  prtzternaturalis  has  commonly  been  construed  by  the 
word  unnatural;  this  is  far  from  its  true  sense  :  it  expresses  a  deviation  from, 
not  an  opposition  to,  the  ordinary  course  of  nature. 


DEFINITION    OF   DISEASE.  9 

nition  thus  modified,  is  more  accurate,  but  is  still  susceptible  of 
improvement.  Every  species  of  functional  derangement,  in  which 
there  is  a  greater  or  less  deviation  from  the  usual  order  of  nature, 
constitutes  a  disease;  but  disease  may  exist  independent  of  func- 
tional disorder.  Hernia,  for  example,  is  a  disease,  but  not  always 
accompanied  by  disturbance  of  the  functions.  Tubercular  degen- 
eration, a  very  serious  disease,  may  occur  in  several  glands,  and 
even  in  a  portion  of  an  important  viscus,  as  the  lungs,  without 
giving  rise  to  apparent  disturbance  of  the  health.  It  has  been 
maintained  by  some  authors,  that  an  anatomical  lesion,  which 
is  not  followed  by  apparent  functional  disorder  should  not  be 
considered  as  a  disease ;  that  the  disease  can  only  be  said  to  exist 
from  the  moment  when  certain  phenomena  of  reaction  render 
it  evident.  Disease,  according  to  them,  and  M.  Littre  adopts  this 
definition,  f  is  ua  vital  reaction,  either  local  or  general,  immediate 
or  mediate,  against  some  obstruction,  disorder  or  lesion."  According 
to  this  definition,  a  change  of  structure,  however  considerable, 
in  those  cases  of  aneurism  at  the  root  of  the  aorta,  which  some- 
times become  far  advanced  without  causing  apparent  disturbance 
of  the  health,  would  not  become  a  disease  till  complete  perforation 
of  the  vessel  should  take  place ;  while  the  same  lesion,  occurring 
in  another  part  of  the  same  vessel,  and  causing  either  compression 
upon  a  neighboring  organ,  or  giving  rise  to  perceptible  pulsations 
through  the  thoracic  walls,  would  constitute  a  disease  almost  from 
its  commencement.  In  a  fracture,  the  disease  would  consist  rather 
in  the  reaction  against  the  lesion,  that  is,  in  the  pain,  difficulty  of 
movement,  and  inflammation  which  is  developed  at  the  surface 
of  the  fragments  and  in  the  contiguous  parts,  than  in  the  ana- 
tomical lesion  itself.  These  two  examples  taken  from  the  most 
familiar  diseases,  show  the  incorrectness  of  this  definition,  which 
has  been  before  pointed  out,  in  considering  that  proposed  by  Syden- 
ham,  within  which  it  is  comprised. 

It  follows  from  these  considerations,  that  it  is  impossible  to 
render  a  satisfactory  definition  of  disease,  without  including 
changes  of  structure,  whether  accompanied  or  not  by  functional 
disturbance. 

Structural  changes  being  in  most  diseases  the  principal,  and 
functional  disorders  occurring,  as  secondary  phenomena,  it  has 
been  thought  by  some  physicians  that  all  diseases  are  necessarily 
connected  with  a  material  organic  lesion,  and  that  disease,  con- 
sidered abstractly,  should  be  defined  an  alteration  occurring  in  the 
structure  of  the  body. 

It  should  be  recollected  that  in  a  great  number  of  diseases,  the 
existence  of  such  an  alteration  is  manifest,  and  is  of  the  highest 
value  in  the  appreciation,  as  well  as  in  the  definition  of  disease. 
It  may  be  also  remarked,  that  the  number  of  affections,  in  which 
these  changes  are  found  to  exist,  is  becoming  more  considerable 
in  proportion  to  the  advance  of  medical  science,  and  will  ultimate- 

f  Dictionnaire  de  Medecine,  ou  Repertoire  general,  vol.  xviii ,  article,  Maladie. 


10  DEFINITION    OF   DISEASE. 

ly  become  indefinitely  increased;  in  addition  to  the  discoveries 
daily  made  by  pathological  anatomists  of  lesion  in  the  solid  parts, 
previously  unnoticed,  chemistry  is  leading  to  similar  results,  by 
bringing  to  light  important  alterations  in  the  fluids  which  enter 
into  the  composition  of  the  human  body,  as  the  bile,  blood,  urine, 
&c.  The  changes  observed  in  the  quantity  and  consistence  of 
certain  fluids,  and  particularly  the  blood  (plethora,  anemia) ;  the 
excessive  accumulation  of  gas,  in  parts  which  naturally  contain 
it,  its  formation  in  parts  to  which  it  is  foreign,  have  added  to  the 
list  of  diseases,  in  which  a  material  alteration  exists.  These 
lesions  of  the  liquid  and  gaseous  fluids,  which  form  a  part  of  the 
human  body,  deserve  to  be  placed  with  those  of  the  solid  parts ; 
and  should,  in  the  absence  of  lesions  occurring  in  the  latter, 
be  comprehended,  at  least  by  inference  in  the  definition  of  the 
disease. 

By  thus  observing  the  progress  of  the  science,  it  may  be  very 
naturally  inferred  that,  in  proportion  as  our  means  of  chemical 
analysis  and  observation  become  more  perfect,  those  diseases  in 
which  hitherto  no  material  lesion  has  been  discoverable,  will  be 
gradually  added  to  those  whose  primitive  lesion  is  already  known, 
and  disease  may  then  be  defined  to  be  an  alteration  occurring  in 
the  structure  of  organs.  But  in  medicine,  more  perhaps  than  in 
any  other  science,  we  must  be  guided  by  facts ;  and  as  it  often 
happens  that  this  alteration  escapes  all  our  means  of  investigation, 
and  the  functional  disturbance  is  alone  appreciable,  and  conse- 
quently that  alone  which,  in  the  present  state  of  our  knowledge, 
indicates  and  constitutes  the  disease,  it  becomes  necessary,  in  at- 
tempting its  definition,  to  characterize  it  by  reference  both  to  mate- 
rial lesions  and  to  functional  derangement. 

In  the  former  editions  of  this  work,  we  defined  disease  to  be  a 
perceptible  change  in  the  position  or  structure  of  parts,  or  in  the 
exercise  of  one  or  many  functions,  relatively  to  the  habitual  health 
of  the  individual. 

We  have  thought  proper,  for  the  sake  of  brevity,  to  strike  out 
the  clause  relating  to  the  changes  of  position  of  organs,  since  such 
a  change  cannot  be  effected,  unless  there  be  also  structural  altera- 
tion of  the  parts :  a  hernia  can  only  follow  a  structural  change  in 
the  parietes  of  the  splanchnic  cavities ;  dislocation  can  only  take 
place  after  rupture,  or  some  other  alteration  in  the  parts,  of  which 
the  articulation  is  composed.  We  would  likewise  omit  the  last 
clause  of  the  definition,  relatively  to  the  habitual  health  of  the  in- 
dividual, as  good  sense  alone  indicates  this  condition,  which  more- 
over would  be  more  appropriately  placed  among  the  considera- 
tions which  precede  the  definition,  where  it  is  presented  with  its 
necessary  developments.  We  have  also  employed  another  expres- 
sion in  place  of  the  word  structure,  which  does  not  so  well  apply, 
in  common  phraseology,  to  the  changes  which  occur  in  the  com- 
position and  quantity  of  the  fluids,  or  to  alterations  in  the  volume 
of  the  solid  parts,  when  at  the  same  time  unaccompanied  by 
manifest  alteration  of  the  tissues.  It  being  impossible  to  define 


DEFINITION    OF    DISEASE.  11 

I 

disease  according  to  its  nature,  and  to  obtain  a  clear  idea  of  it 
except  from  what  is  revealed  to  us  by  its  phenomena,  we  give  the 
following  definition :  a  perceptible  disorder  occurring,  either  in  the 
material  disposition  of  the  parts  composing  the  living  body,  or  in 
the  exercise  of  its  functions.* 

Some  authors  have  endeavored  to  create  a  distinction  between 
affection  and  disease,  expressions  generally  employed  as  synony- 
mous. It  has  been  thought  by  some  that  the  word  affection  is 
more  appropriately  applied  to  surgical  cases,  while  those  strictly 
medical,  would  be  better  indicated  by  the  word  disease.  Others 
have  maintained  that  disease  consists  in  structural  lesion,  and  af- 
fection in  the  sensible  phenomena  arising  from  such  lesion. 

Sprengel,  who  presents  this  distinction,  thinks  it  should  serve  as 
a  base  for  the  division  of  pathology  into  general  and  special;  the 
former  treating  of  diseases,  the  latter  of  affections.  In  the  sense  in 
which  Sprengel  employs  these  two  expressions,  both  belong  equally 
to  general,  and  descriptive  or  special  pathology.  This  distinction 
between  affection  and  disease  ought  then  to  be  rejected,  as  con- 
trary to  common  acceptation,  and  as  rendering  the  language 
obscure  without  elucidating  the  subject.  The  words  affection  and 
disease  therefore,  in  medical  phraseology,  are  used  synonymously, 
although  the  latter,  considered  in  its  most  general  sense,  admits  of 
a  different  signification. 

II.  Having  defined  disease  in  general  according  to  the  principles 
previously  established,  we  shall  proceed  to  consider  the  mode  of 
defining  diseases  respectively.  These  considerations  belong  to 
general  pathology,  inasmuch  as  they  apply  to  all  diseases. 

To  obtain  a  correct  definition  of  each  particular  disease  is  of  far 
more  importance,  than  the  attainment  of  a  clear  idea  of  disease  in 
general. 

Being  ignorant  of  the  nature  of  diseases  respectively,  as  well  as 
of  disease  in  general,  it  is  necessary  that  we  define  them  also  ac- 
cording to  their  sensible  phenomena. 

It  has  been  recently  advanced,  that  a  disease  can  only  be  defined 
by  determining  which  is  the  organ  affected  and  the  character  of 
that  affection ;  but  this  kind  of  definition  which  can  only  apply  to 
a  limited  number  of  diseases,  is  not  strictly  a  definition.  To  say 
that  pleurisy  is  an  inflammation  of  the  pleura ;  tabes  mesenterica, 
a  tubercular  degeneration  of  the  mesenteric  glands  ;  ascites,  an  ef- 
fusion of  serum  into  the  peritoneum ;  epistaxis,  a  haemorrhage  from 
the  pituitary  membrane ;  is  to  give  a  signification  of  the  word,  and 
not  a  definition  of  the  disease.  Another  and  more  serious  inconve- 
nience connected  with  this  kind  of  definition,  is  the  uncertainty  in 
respect  to  the  seat  of  certain  diseases,  and  the  conflicting  opinions 
among  physicians  on  this  point.  How  various,  for  example, 

*  This  definition  appears  to  us  more  accurate  than  any  other,  although  defec- 
tive in  some  respects  ;  this  imperfection  is,  perhaps,  inherent  in  the  subject  un- 
der consideration.  Health  and  disease  are  often  confounded.  How  is  it  possible 
to  define  with  strict  accuracy  things  not  always  distinct  ? 


12  DEFINITION   OF   DISEASE. 

would  have  been  the  definitions  of  intermittent  fever,  whose  seat 
has  been  placed  in  the  liver,  spleen,  stomach,  intestines,  nervous 
system,  skin,  vena  porta,  lymphatic  vessels  of  the  mesentery,  and 
to  what  confusion  would  these  contradictory  statements  have  given 
rise !  It  is  necessary  then,  in  order  that  the  definition  be  always 
intelligible,  to  define  these  affections  according  to  their  phenomena. 
There  are  also  cases,  in  which  the  manifest  cause  of  diseases  be- 
comes an  accessory  element  in  their  definition :  contusions,  wounds, 
lead  colic,  asphyxia,  syphilis,  variola,  &c.,  cannot  be  accurately  de- 
fined, unless  the  cause  which  produced  them  be  indicated. 

In  general,  in  order  to  the  correct  definition  of  a  disease,  it  is 
necessary  to  collect  the  greatest  possible  number  of  detailed  cases, 
relating  to  it ;  to  compare  them  with  each  other,  so  as  to  isolate 
those  phenomena  which  are  constant,  from  those  which  are  simply 
accidental. 

The  phenomena  which  are  found  to  occur  in  all  the  cases,  or  at 
least  in  the  majority,  form  the  characteristic  features  of  the  dis- 
ease ;  their  brief  enumeration  will  present  an  outline  of  the  latter, 
constituting  its  definition. 

Some  diseases  appear  with  such  different  degrees  of  intensity, 
that  it  would  be  impossible  to  include  in  a  common  description 
these  various  forms  of  the  same  affection :  cerebral  haemorrhage, 
for  example,  gives  rise  to  phenomena  so  various,  according  to  the 
size  of  the  coagulum,  that  it  is  indispensable,  in  order  to  give  a  cor- 
rect idea  of  this  disease,  to  present  a  descriptive  definition  of  its 
principal  forms,  as  in  natural  history,  in  which  the  representation 
of  a  plant  or  animal  is  given,  in  its  principal  phases  of  existence, 
and  in  its  various  proportions.  The  remark  of  Grimaud,  that  the 
thorough  knowledge  of  a  disease  is  only  to  be  obtained,  by  study- 
ing it  at  the  age,  and  in  the  sex,  temperament  and  climate,  which 
observation  has  shown  to  be  congenial  with  it,  is  incorrect;  "for," 
says  he,  "  every  disease,*  like  every  natural  being,  appears  in  its 
true  light,  and  enjoys  the  whole  plenitude  of  its  existence,  only  when 
formed  and  developed  under  a  concurrence  of  circumstances,  which 
are  analogous  to  it,  and  equally  tend  to  favor  its  production."  The 
physician,  whose  knowledge  of  a  disease  only  extends  to  its  se- 
verest form,  can  have  but  an  imperfect  idea  of  it,  being  acquainted 
only  with  its  exceptional  form.  It  should  be  studied,  on  the 
contrary,  in  all  its  varieties,  and  if  there  be  any  which  deserve 
particular  attention,  it  should  first  be  those  of  most  frequent  oc- 
currence, and  afterwards  those  whose  characteristics  are  least  ap- 
parent, the  former  on  account  of  their  greater  utility,  the  latter, 
because  of  their  more  difficult  diagnosis.  But,  we  repeat  it,  the 
definition  of  a  disease  is  only  correct,  so  far  as  it  comprehends  all 
the  forms  which  the  latter  is  capable  of  presenting.  —  O. 

*  Grimaud.    Cours  de  Fttvres,  vol.  i.,  p.  2. 


NOMENCLATURE,    SYNONOMY,    ETYMOLOGY,    OF    DISEASES.  13 


CHAPTER    III. 

NOMENCLATURE    OF    DISEASES. SYNONOMY. ETYMOLOGY. 

I.  Nomenclature.  There  is  perhaps  no  science,  the  nomencla- 
ture of  which  is  so  defective,  as  that  of  pathology.  This  is  doubt- 
less, in  part,  attributable  to  the  very  gradual  progress  made  in  the 
knowledge  of  diseases.  If,  like  chemistry,  the  science  of  pathology 
had  made  a  sudden  and  rapid  advance,  the  old  terms  would  have 
been  replaced  by  others  formed  on  more  regular  bases.  But  the 
case  has  been  far  otherwise,  and  nothing  can  be  more  preposterous 
than  the  collection  of  names  by  which  diseases  have  been  desig- 
nated. Some  have  been  named  from  their  known  or  supposed 
seat,  as  pleuritis  and  hypochondriasis  ;  or  from  their  causes,  as 
colds,  &c. ;  others  from  the  places  and  seasons  in  which  they  ap- 
pear, as  the  camp,  harvest  and  autumnal,  fevers,  ( Grant ;)  from 
the  country  where  they  originated,  as  the  typhus  of  America  ;  from 
the  people  who  transmitted  them,  as  the  French  disease,  (a  term 
applied  by  the  Italians  to  syphilis ;)  from  the  animal  which  com- 
municates it,  as  vaccinia ;  others,  from  one  of  the  principal  symp- 
toms, as  hydrophobia,  chorea,  &c.  In  eruptive  diseases,  the  color 
of  the  skin  has,  in  many  instances,  suggested  the  name  by  which 
they  are  designated ;  rubcola  and  scarlatina  are  examples.  The 
word  variola  seems  to  have  had  the  same  origin,  and  to  signify 
that  diversity  of  color  which  the  skin  presents,  when  its  surface  is 
covered  with  white  pustules,  or  yellowish  or  brownish  crusts,  sur- 
rounded by  a  red  and  sometimes  brown  areola,  and  separated  by 
spaces  in  which  the  natural  color  remains  unchanged.  The  par- 
ticular form  of  certain  eruptions,  the  manner  in  which  they  are 
disposed  upon  the  skin,  their  appearance  during  the  night,  have  led 
to  the  adoption  of  names  indicating  these  different  circumstances, 
as  miliaria,  herpes  zoster,  epinyctis  ;  other  affections  have  received 
names  relating  to  their  progress  or  duration,  as  intermittent,  con- 
tinued, and  remittent  fevers.  The  insidious  form  of  some  diseases 
has  caused  the  term  malignant  to  be  applied  to  them.  There  are 
others  which  have  been  designated,  from  a  sort  of  resemblance  to 
certain  products  of  human  industry,  or  some  object  of  natural  his- 
tory, as  tympanitis,  clavus,  cancer,  polypus,  talpa,  and  elephantia- 
sis. Others  have  received  names  indicative  of  their  supposed  na- 
ture, as  putrid  and  bilious  fevers ;  and  again,  indicative  of  the 
kind  of  organic  alteration  which  constitutes  the  disease,  as  tubercle, 
melanosis,  eneephaloid  disease ;  others  have  been  named  from  the 
physician  who  first  described  them,  as  Potts'  disease,  Bright's 
disease.  Besides  these  principal  terms,  some  epithet  indicating  its 
degree  of  severity,  form,  termination  or  mobility,  has  been  added 
to  the  name  of  the  disease.  Examples  of  this,  are  the  variola  benig- 


14  NOMENCLATURE,    SYNONOMY,    ETYMOLOGY,    OF    DISEASES. 

na,  apoplexia  fulminans,  tinea  favosa,  angina  gangrccnosa,  febris 
ephemera,  erysipelas  erraticum. 

It  is  evident  from  this  brief  survey,  that  no  rule  has  been  ob- 
served in  the  selection  of  the  names  under  which  diseases  have  been 
described,  and  that  incongruity  prevails  thoughout  pathological 
nomenclature.  But  another  and  more  serious  inconvenience  which 
it  presents,  is,  that  many  terms  are  false,  and  consequently  liable 
to  lead  to  error ;  such  are  those  based  on  the  supposed  seat  of  the 
disease,  and  upon  its  intimate  nature.  In  some  cases,  the  error  is 
still  more  palpable,  affecting  some  point  relative  to  the  origin  of  the 
disease,  or  some  one  of  its  more  apparent  phenomena.  Thus,  the 
disease  of  Siam,  originated  in  America ;  the  hepatic  flux  does  not 
generally  come  from  the  liver,  and  the  fluor  albus  may  be  of  other 
colors,  &c. 

The  defects  of  such  a  nomenclature  are  too  striking,  not  to  have 
led  many  physicians  to  attempt  their  correction  ;  but  it  should  be 
remarked,  that  these  corrections  have  in  nearly  every  case  been 
partial,  and  that  M.  Piorry  has  been  the  first  to  propose  a  complete 
system  of  nomenclature  for  all  diseases,  established  on  uniform 
bases.  These  partial  corrections,  failing  to  produce  a  proper  regu- 
larity, have  proved  rather  injurious  than  useful.  In  some  cases, 
more  appropriate  names  have  -been  substituted  for  those  which 
were  vague  or  erroneous,  but  the  latter  have  not  been  totally  aban- 
doned ;  so  that  many  diseases  have  received  a  variety  of  names, 
with  which  it  is  necessary  to  become  familiar ;  no  less  than  twenty 
have  been  applied  to  yellow  fever.  The  effect  of  these  numerous 
pathological  terms,  has  been  to  increase  the  number  of  words, 
without  aiding  in  the  elicitation  of  truth. 

Another,  and  still  more  serious,  inconvenience  results  from  these 
partial  corrections ;  some  authors,  not  content  with  adding  new 
names  to  the  old,  have  transferred  the  same  term  from  one  disease 
to  another,  under  the  pretext  that  it  was  less  appropriate  to  that  to 
which  it  had  been  previously  applied,  than  to  the  one  which  it  was 
henceforth  to  represent.  The  troublesome  results  of  these  pretend- 
ed improvements  are  easily  discernible ;  confusion  in  pathological 
language  has  been  the  necessary  consequence. 

It  will  be  perhaps  asked,  if,  in  the  present  state  of  the  science,  a 
new  nomenclature  could  with  advantage  be  established,  and  on 
what  basis.  When  we  consider  tjie  imperfections  and  incongruity 
of  nomenclature,  as  it  now  exists,  we  become  convinced  of  the  im- 
portance of  substituting  a  methodical  nomenclature,  which  shall  in- 
dicate the  characteristic  features  of  each  disease,  and  by  which  we 
shall  be  enabled  to  establish  their  relations  with  each  other.  But 
if  it  be  also  considered,  how  much  the  difficulties  connected  with 
the  study  of  the  science  become  increased  by  such  a  multiplicity  of 
names,  and  that,  in  the  present  state  of  our  knowledge,  it  is  impos- 
sible to  present  any  system  of  nomenclature,  which  shall  be  satis- 
factory to  all,  as  the  attempts  of  M.  Piorry  sufficiently  prove ;  and, 
lastly,  if  we  regard  the  apparent  contradictions  to  which  new  terms 
give  rise,  and  the  unfavorable  inferences  of  the  public  with  respect 


NOMENCLATURE,    SYNONOMY,    ETYMOLOGY,    OF   DISEASES.  15 

to  the  certainty  of  medicine,  we  shall  be  led  to  conclude  that  the 
advantages  of  a  new  nomenclature  would  be  more  than  counter- 
balanced by  the  inseparable  inconveniences  connected  with  it.  "  Si 
nunc  imponenda  essent  nomina"  says  Morgagni,*  "  non  dubito 
quin  plura  excogitari  possint  meliora  et  cum  vero  magis  congru- 
entia ;  sed  proestat,  opinor,  verum  postea  animadverswn  docere, 
vetera  autem  et  usitata  nomina  retincre" 

There  are  some  circumstances,  however,  in  which  it  becomes 
necessary  to  add  to  pathological  nomenclature ;  as  upon  the  dis- 
covery of  an  affection  not  before  described,  and  also  when  different 
diseases  have  been  confounded  under  the  same  name.  In  both 
cases,  it  is  indispensably  necessary,  even  the  enemies  of  neologism 
will  admit,  to  seek  a  new  name  for  the  disease  just  discovered  or 
pointed  out. 

II.  Synonomy.     The  same  disease  having,  in  some  instances, 
received  a  variety  of  names,  and  the  same  name  having  been 
applied  to  many  diseases  by  different  authors,  the  study  of  the 
various  names  of  diseases,  with  their  different  significations,  has 
become    also  indispensable.     This  is,    as   it    were,    an  artificial 
branch  which  man  has  added  to  pathology,  without  any  real  pro- 
fit, though  not  without  necessity.     Synonomy  of  diseases  has  con- 
sequently become  a  highly  important  point  in  their  history,  render- 
ing their  study  more  complicated,  an  irremediable  inconvenience, 
but  enabling  us  to  avoid  much  confusion. 

III.  The  Etymology  of  diseases  is  one  of  the  least  interesting 
points  in  pathology.     It  is,  however,  like  many  other  things,  a 
knowledge  of  which  is  of  little  utility,  but   ignorance  of  which 
would  be  attended  with  inconvenience.     No  one  doubts   that  a 
physician  may  skilfully  treat  a  disease,  without  being  acquainted 
with  the  origin  of  its  name ;  but  it  is  equally  certain,  that  it  would 
be  embarrassing,  and  even  injurious  for  him  to  appear  ignorant  in 
ther  presence  of  some  persons,  of  the  etymology  of  a  word  which 
he  daily  employs.     An  acquaintance  with  the  exact  value  of  the 
terms  in  common  use,  is  moreover  convenient  to  the  physican; 
medical  phraseology  would,    otherwise,  be  to  him  unintelligible. 
Most  of  the  names  which  have  been  applied  to  diseases,  are  of 
Greek  and  Latin  origin ;  and  as  the  study  of  these  two  languages 
should  always  precede   that  of  medicine,  it  is  rarely  necessary 
for  the  physician  to  seek  the  etymology  of  the  terms  of  which  he 
makes  use. 

The  etymology  of  the  various  terms  used  in  pathology  but  im- 
perfectly indicates  the  meaning  which  should  be  attached  to  them. 
It  rarely  gives  an  accurate,  and  often  presents  a  totally  incorrect 
idea  of  the  disease.  Thus  the  words  phlegmon,  and  phlegmasice, 
from  yJeycflj  { I  burn,'  merely  give  the  idea  of  heat,  which  is  but  one 
of  the  symptoms  of  the  disease  ;  the  word  peripneumony,  from  n^i, 
'  around,'  and  nvevuonj,  l  lung,'  indicates  an  affection  seated  around 
the  lungs,  whereas  it  consists  in  inflammation  of  this  viscus  itself. 

*  Morgagni,  Epist  xvi.  14. 


16  SEAT    OF    DISEASES. 


and  not  of  the  surrounding  parts.  Thus,  etymology,  in  the  former 
case,  presents  an  imperfect,  in  the  latter,  an  erroneous,  idea  of  the 
disease.^  —  O. 


CHAPTER  IV. 

4 

SEAT    OF    DISEASES. 

IT  may  be  remarked  generally,  that  all  the  constituent  parts  of 
the  human  body  are  susceptible  of  some  change,  and  consequently 
may  become  affected  with  diseases  of  greater  or  less  severity.  The 
susceptibility  to  the  influence  of  the  various  morbific  causes,  varies 
in  different  organs ;  the  skin  and  mucous  membranes  are  of  all 
tissues,  those  in  which  diseases  are  most  frequently  observed.  The 
organs  which  are  deeply  seated,  and  which  have  no  direct  commu- 
nication with  external  objects,  are  less  prone  than  all  others  to  the 
action  of  disease. 

It  is  not  always  easy  to  determine  the  seat  of  diseases,  and  the 
history  of  medicine  shows  how  great  has  been  the  diversity  of 
opinion  on  this  point.  During  the  reign  of  humorism,  the  primi- 
tive seat  of  most  diseases  was  supposed  to  be  in  some  one  of  the 
fluids  which  enter  into  the  organization  of  the  human  body.  The 
Solidists,  who  came  afterwards,  supposed  the  humors  to  be  purely 
passive  in  the  phenomena  of  life,  and  considered  the  solids  to  be 
the  seat  of  all  diseases.  Time  has  dealt  justly  with  these  erroneous 
opinions,  and  observation  has  shown  that  the  exclusive  claims  of 
both  these  systems  are  alike  inadmissible. 

It  should  be  recollected  that  many  diseases  have  a  complex  seat, 
primarily  affecting  the  solid  parts,  and  afterwards  extending  to  the 
fluids  of  the  body,  or  vice  versa.  The  first  stage  of  phlebitis  pre- 
sents an  example  of  a  disease  at  first  confined  to  a  single  tissue, 
but  soon  followed  by  a  secretion  of  pus  from  the  suffering  part ; 
this  morbid  product  being  carried  along  by  the  circulatory  move- 
ment, is  mixed  with  the  blood,  which  becomes  altered,  and,  by  its 
effect  upon  other  organs,  produces  phlegmasiae  and  suppurations. 
In  variola,  on  the  contrary,  and  in  the  other  contagious  eruptive 

*  Although  the  etymology  of  diseases  is  generally  of  slight  importance,  it  is  not 
in  many  cases  devoid  of  interest.  The  names  which  have  been  given  to  diseases 
are  often  connected  with  the  history  of  medicine,  and  the  theories  to  which  it  has 
given  rise  ;  such  are  the  terms  humoral  fever ,  nervous  fever.  Etymology  may  also 
give  rise  to  conjectures  upon  some  of  the  circumstances  relating  to  the  particular 
history  of  a  disease,  &c.  The  term  morbtlli,  for  example,  by  which  rubeolahas 
been  designated,  would  lead  us  to  suppose  that  there  appeared,  simultaneously 
with  it,  another  and  more  severe  affection,  bearing  resemblance  to  it,  which  was 
called  morbus,  a  name  always  given  to  epidemic  diseases.  This  circumstance 
would  add  weight  to  the  opinion  generally  entertained,  that  rubeola,  which  origi- 
nated in  the  same  country  with  variola,  first  appeared  at  about  the  same  period. 


SEAT    OF   DISEASES.  17 

fevers,  in  which  the  blood  appears  to  be  the  primary  seat  of  the 
disease,  the  eruption  makes  its  appearance  upon  the  skin  and  mu- 
cous membranes,  a  few  days  after  this  alteration  has  taken  place. 

There  are  some  diseases  which  affect  nearly  all  the  tissues  of 
the  economy,  as,  inflammation,  cancer,  tubercles,  and  syphilis. 
Others  are  observed  in  but  a  few  ;  dropsy,  for  example,  is  peculiar 
to  the  membranes  which  line  the  interior  of  cavities,  and  to  the 
cellular  tissue  ;  spontaneous  haemorrhage  rarely  occurs  except  from 
the  mucous  membranes.  Haemorrhage  may,  however,  take  place 
in  other  parts,  and  dropsy  may  be  formed,  by  means  of  accidental 
cysts,  in  parts  naturally  protected  from  it  by  their  structure. 
There  are  also  other  diseases,  which  appear  to  be  constantly  and 
exclusively  confined  to  the  same  anatomical  element,  wherever 
this  be ;  this  is  probably  the  case  in  rheumatism  and  gout,  which 
are  peculiar  to  the  muscular  and  fibrous  tissues. 

Many  diseases  have  a  fixed  seat,  that  is,  they  become  developed 
and  terminate  in  the  same  part  where  they  originally  appeared : 
others,  on  the  contrary,  successively  invade  the  neighboring  parts, 
as  certain  phagedenic  ulcers,  cancer,  erysipelas,  and  perhaps  most 
of  the  phlegmasiae,  called  spontaneous.  There  are  others  whose 
seat,  which  is  essentially  vague  and  moveable,  is  constantly  vary- 
ing, as  is  observed  in  rheumatism  and  gout,  the  mobility  of  which 
affections  constitutes  one  of  their  most  essential  characteristics. 
There  are  also  certain  nervous  affections,  which  successively  ap- 
pear in  parts  remote  from  each  other,  and  haemorrhages  are  equal- 
ly liable  to  change  their  seat. 

There  are  many  diseases  which  affect  but  a  portion  of  the 
economy ;  there  are  others,  which  appear  simultaneously  in  parts 
more  or  less  remote  from  each  other,  exhibiting  the  same  form  and 
characteristics.  The  former  have  but  a  single  seat,  the  latter  are 
disseminated,  or  have  a  multiple  seat.  To  the  first  belong  the 
visceral  and  membranous  phlegmasiae,  as  pneumonia  or  pericar- 
ditis ;  to  the  second,  urticaria,  variola,  rubeola,  the  syphilitic 
eruptions,  morbus  macidosus,  &c.  These  latter  affections,  to 
which  we  have  applied  the  term  disseminated,  deserve  particular 
attention,  from  the  conditions  under  which  they  are  developed. 
These  multiple  lesions  are  indeed  almost  always  secondary,  and 
the  physician  may  in  most  cases  recognize  the  affection  which 
gave  rise  to  them,  and  to  which  the  treatment  should  be  directed. 

The  organs  which  exist  in  pairs  are  often  simultaneously  affect- 
ed with  the  same  disease.  It  is  rare  to  see  spontaneous  ophthalmia 
confined  to  one  of  the  conjunctivae,  or  bronchitis  or  emphysema 
affecting  but  one  lung.  There  are  certain  chronic  exanthemata 
which  appear  simultaneously  in  both  armpits,  in  the  two  groins, 
and  in  corresponding  parts  of  the  same  limbs.  In  rheumatism, 
corresponding  articulations  become  generally  successively  affected. 
The  same  law  is  observed  in  regard  to  the  deep  seated  organs.  It 
has  been  clearly  shown  by  M.  Bizot,  that  the  numerous  changes 
which  take  place  in  the  arteries,  are  almost  always  affected  si- 
multaneously in  the  symmetrical  vessels,  and  at  corresponding 
2* 


18  SEAT   OF   DISEASES. 

points.*  There  are,  however,  some  exceptions  to  this  law ;  the 
two  testicles,  or  the  mammae,  for  example,  which  often  become 
singly  affected  with  inflammation  or  carcinomatous  disease,  are 
rarely  the  seat  of  either  of  these  affections  simultaneously. 

It  has  heen  long  observed  that  the  age  has  a  marked  influence 
upon  the  seat  of  diseases.  During  infancy  the  head  is  the  seat  of 
numerous  affections;  hydrocephalus,  tubercular  meningitis,  the 
various  eruptions  of  the  hairy  scalp,  excoriations  of  the  lips,  nose 
and  ears,  apthre,  grangrene  of  the  mouth,  and  epistaxis  are  pecu- 
liar to  'this  period ;  the  lightest  affections  are  accompanied  with 
delirium,  the  submaxillary  glands  are  often  engorged,  and  the 
larynx  is  the  seat  of  very  serious  diseases;  it  is  at  this  period 
that  croup  is  most  commonly  observed.  At  puberty  and  during 
the  period  of  youth,  affections  of  the  chest,  as  inflammations  of 
the  pleura  and  lungs,  hemoptysis,  and  bronchitis,  become  more 
frequent ;  it  is  then  that  the  first  signs  of  cardiac  disease  often 
manifest  themselves,  and  so  common  is  the  occurrence  of  phthisis 
pulmonalis  at  this  period,  that  it  was  for  a  long  time  supposed 
never  to  appear  except  between  the  ages  of  fifteen  and  thirty. 
While  thoracic  disease  is  more  frequent  during  the  period  of 
youth,  that  of  adult  age  is  more  prone  to  diseases  of  the  abdomen ; 
it  is  at  this  period  that  most  organic  affections  of  the  abdominal 
viscera  become  developed;  diseases  of  the  stomach,  intestines, 
ovaries,  testicles,  liver,  bladder  and  uterus  rarely  occur  before  this 
time.  The  haemoptysis  of  youth,  which  succeeds  the  epistaxis  of 
childhood,  is  followed  in  adult  age  by  the  hgemorrhoidal  flux,  which 
is  as  peculiar  to  this  period,  as  the  others  to  the  preceding.  Lastly, 
in  old  age,  while  the  abdomen  continues  the  seat  of  various  diseases, 
those  of  the  urinary  organs  become  more  frequent,  and  the  head 
again  becomes  prone  to  morbific  action ;  dementia,  paralysis,  effu- 
sion of  blood  into  the  brain,  softening  of  its  substance,  deafness, 
cataract,  &c.,  are  diseases  as  common  during  this,  as  they  are  rare 
at  other  periods  of  life. 

To  this  observation  respecting  the  frequency  of  diseases  of  the 
head,  chest  and  abdomen  at  particular  periods  of  life,  although 
generally  true,  there  are  numerous  exceptions.  Without  referring 
to  the  diseases  produced  by  mechanical  causes,  whose  seat  is 
determined  by  external  circumstances,  we  often  see  children 
affected  with  pulmonary  catarrh,  phthisis,  and  various  forms  of 
enteritis.  Scrofulous  enlargement  of  the  mesenteric  glands,  and 
intestinal  worms,  are  of  more  frequent  occurrence  during  child- 
hood than  at  other  periods ;  mania,  whose  seat  appears  to  be  in  the 
brain,  is  more  common  in  youth  and  adult  age ;  simple  meningitis 
•occurs  at  all  periods  of  life,  and  pneumonia  is  one  of  the  acute 
diseases  most  frequently  observed  in  old  age.  But  however  nu- 
merous the  exceptions,  they  are  insufficient  to  invalidate  the  gen- 
eral rule. 

It  has  been  stated  that  the  seasons,  as  well  as  the  age,  exert 

*  Memoires  de  la  Soc.  Med.  d'Observation.    Paris,  1836,  t.  1,  p.  399. 


ETIOLOGY.  19 

a  marked  influence  upon  the  seat  of  diseases ;  that  in  winter, 
cerebral  diseases  prevail ;  in  spring,  those  of  the  chest ;  while  ab- 
dominal affections  are  more  prevalent  in  summer  and  autumn. 
This  assertion  does  not  so  generally  apply  as  the  preceding, 
although  not  without  foundation,  particularly  if  it  be  considered 
with  exclusive  reference  to  acute  diseases. 

Such  are  the  general  points  of  view,  in  which  the  seat  of  dis- 
eases may  be  considered,  the  difficulties  and  modes  of  deter- 
mining which,  will  be  particularly  considered  in  the  chapter  on 
diagnosis.  — O. 


CHAPTER  V. 

ETIOLOGY,    OR    THE   CAUSES    OF    DISEASE.* 

THE  most  general  signification  of  Etiology  in  all  the  sciences, 
is  the  study  of  causes  ;  in  medicine,  its  object  is  the  knowledge 
of  morbific  causes. 

Under  the  title  morbific  causes,  is  included  every  thing  which 
produces  disease,  and  all  that  contributes  to  its  development. 

The  causes  of  disease  are  everywhere  present,  both  around  and 
within  us.  The  things  most  necessary  to  our  existence,  as  the 
air  we  breathe,  the  food  and  fluids  which  restore  our  daily  loss  of 
substance,  the  products  of  human  industry  by  which  life  is 
rendered  more  comfortable  and  happy,  themselves  give  rise  to  the 
ills  with  which  we  are  afflicted. 

The  different  organs,  which  united,  constitute  tfye  economy,  and 
which  are  designed  for  the  preservation  of  the  entire  system,  of 
which  they  form  part,  may  also,  in  certain  circumstances,  disturb 
its  harmony ;  the  muscles,  whose  use  is  to  transport  us  from  one 
place  to  another,  may  cause  displacement  and  even  fracture  of 
the  bones ;  the  teeth,  the  eye-lashes,  the  nails,  by  their  irregular 
development,  sometimes  occasion  diseases  of  a  more  or  less  seri- 
ous nature ;  gestation,  and  especially  the  expulsion  of  the  fostus, 
become  under  certain  conditions  the  sources  of  danger  and  death. 
When  we  thus  behold,  within  the  system  and  without,  the  things 
most  indispensable  to  human  life  and  to  the  preservation  of  the 
species,  become  in  some  circumstances  the  causes  of  the  maladies 
by  which  we  are  afflicted,  we  are  tempted  to  admit  with  Testa, 
that  there  is  not,  properly  speaking,  any  morbific  cause,  nothing 
in  itself  injurious :  "  Nikil  proprie  morbificum,  nihil  noxium 
natura/sua"  But  this  assertion,  although  true  in  respect  to  the 
greater  number  of  causes  which  disturb  the  health,  becomes  the 
opposite,  when,  reviewing  all  the  causes  of  disease,  we  come  to 

*Ali(a,  cause  ;  Aoyo?,  narration. 


20  ETIOLOGY. 

the  contagious  principles,  which  are  certainly,  in  themselves  and 
despite  the  abuse  that  may  be  made  of  them,  morbific  agents. 

The  causes  of  disease  being  very  numerous  and  varied,  the 
necessity  for  a  division  of  them  has  always  been  experienced : 
they  have  been  divided  into  external,  or  those  which  surround 
the  individual;  internal,  existing  within  him;  jjrificipal,  or 
those  which  act  an  important  part  in  developing  diseases  ;  accesso- 
ry, which  exert  but  little  influence  in  their  production ;  remote, 
which  prepare  or  determine  the  hidden  alteration  constituting 
the  essence  or  proximate  cause  of  the  disease ;  predisposing, 
which  gradually  modify  the  economy  and  dispose  to  various  affec- 
tions ;  occasional,  which  provoke  the  development  of  such 
affections. 

The  terms  physical  and  chemical,  have  been  applied  to  those 
causes  which  act  in  accordance  with  the  laws  of  physics  and 
chemistry,  and  which  would  affect  the  dead  equally  with  the  liv- 
ing body :  such  are  instruments  capable  of  inflicting  wounds, 
caustic  substances,  etc. ;  the  term  ^physiological  is  applied  to  those 
which  need  the  co-operation  of  a  vital  reaction  in  the  organ 
which  receives  their  impressions ;  local,  to  those  whose  action 
affects  but  a  portion  of  the  economy ;  general,  to  those  which  ex- 
tend their  influence  over  all ;  negative,  to  those  which  consist  in 
the  abstraction  of  conditions  necessary  to  health ;  and  the  oppo- 
site, positive,  to  those  which  act  by  their  own  power  in  the  pro- 
duction of  diseases.  Material  and  immaterial  causes  have  been 
admitted,  according  as  they  are  or  are  not  recognized  by  our  senses. 
Finally,  as  there  is  a  certain  number  of  diseases  which  occur 
without  appreciable  cause,  concealed  or  occult  causes  have 
necessarily  been  admitted,  and  these  have  been  ascribed  by 
many  authors  to  certain  inappreciable  qualities  of  the  atmosphere, 
to  which  the  .development  of  epidemics  may  be  attributed. 
There  are  serious  inconveniences  attending  each  of  these  divis- 
ions. The  proximate  cause,  which  is  nothing  else  than  the  very 
essence  of  the  disease  and  the  peculiar  modification  of  the  organism 
which  constitutes  it,  cannot  be  reckoned  among  the  causes  which 
produce  it.  Among  the  occasional  causes,  circumstances  entirely 
dissimilar  are  enumerated :  the  impression  of  cold,  for  instance, 
which  at  one  time  developes  pneumonia,  at  another,  occasions 
anasarca,  and  which  most  frequently  is  productive  of  nothing 
morbid,  is  placed  in  the  same  category  with  wounding  instru- 
ments and  poisons,  which  always  produce  definite  effects  upon 
the  system.  It  is  unnecessary  to  insist  upon  the  imperfection  of 
each  of  these  divisions ;  neither  of  them  possesses  the  advantage 
of  uniting  those  causes  which  have  an  analogous  action ;  and  yet 
it  is  this  very  circumstance  which  should  serve  as  a  foundation 
for  the  most  natural  division  of  morbific  causes. 

Among  these  causes  there  are  those  which  are  constantly  fol- 
lowed by  the  same  diseases ;  for  them  we  reserve  the  name  deter- 
mining. Others,  whose  action  is  often  uncertain  and  always  ob- 
scure, may  be  subdivided  into  two  series.  In  the  first,  we  place 


ETIOLOGY. 


21 


whatever  serves,  by  gradually  modifying  the  economy,  to  pre- 
pare it  for  any  particular  affection,  and  everything  constituting 
the  aptitude  for  being  so  affected  :  these  are  predisposing  causes. 

In  the  second  series  we  rank  those  whose  action,  usually  tran- 
sient, only  hastens  the  development  of  a  disease,  to  which  the 
patient  was  predisposed  :  to  the  latter  we  give  the  name  occasion- 
al or  exciting  causes. 

Thus  we  admit  three  orders  of  morbific  causes,  which  we  dis- 
tinguish by  the  appellations  determining,  predisposing  and  occa- 
sional. We  shall  rapidly  review  the  chief  causes  which  belong 
to  each  of  these  three  divisions,  and  shall  afterwards  offer  some 
general  considerations  upon  their  mode  of  action  in  the  production 
of  disease. 


ARTICLE  FIRST. 
Determining  Causes. 

DETERMINING  causes,  which  constantly  give  rise  to  the  same  af- 
fection, if  we  except  certain  conditions  more  or  less  well  known, 
exhibit  in  almost  every  instance,  either  in  themselves  or  in  the  dis- 
ease which  they  produce,  some  peculiarity.  The  hot  body  which 
burns,  the  cold  which  freezes,  the  gases  which  poison  or  cause 
asphyxia,  the  body  which  inflicts  a  wound,  the  poison  which  nar- 
cotizes or  causes  convulsions,  are  certainly  special  causes,  in  like 
manner  as  the  diseases  which  they  induce  are  themselves  unlike 
all  others.  This  it  is  which  led  us  in  the  former  editions  of  this 
work,  to  class  these  morbific  agents  among  the  specific  causes,  and 
to  use  synonymously  the  terms  specific  and  determining  causes. 

Notwithstanding,  we  now  think  that  a  more  strict  signification 
should  be  given  to  these  words,  and  one  more  in  accordance  with 
general  usage  :  by  specific  causes,  then,  will  be  understood  those 
which  produce  specific  diseases,  and  by  specific  diseases,  those 
which  cannot  be  developed  except  by  one  and  the  same  cause,  as 
syphilis,  rabies,  variola.  Those  causes  whose  action  is  equally  di- 
rect and  constant,  but  which  give  rise  to  diseases  which  other 
causes  may  also  produce,  will  be  designated  common  determining 
causes ;  burns  and  wounds,  for  instance,  may  be  produced  by  vari- 
ous agents.  We  may  add,  that  the  greater  part  of  the  common 
determining  causes  act  by  virtue  of  physical  or  chemical  laws, 
and  that  their  action  can  be  explained  by  these  laws.  Specific 
causes,  on  the  contrary,  in  their  mode  of  action,  are  inexplicable, 
either  by  means  of  physics  or  chemistry.  Such  are  the  motives 
which  have  induced  us  to  divide  these  two  classes  of  causes  and 
to  study  them  separately. 

$  I.  Common  determining  Causes.  These  may  be  diffused  in 
the  atmosphere  (tircumftisa),  brought  in  contact  with  our  bodies, 
(applicata),  or  introduced  into  our  organs  (ingesta) ;  they  may 
exist  within  us  and  depend  upon  derangement  of  the  evacuations 


22  ETIOLOGY. 

(excreta),  of  the  movements  (acta)  or  of  the  perceptions  (percep- 
ta)  ;  they  will  be  pointed  out  in  this  order,  which  is  the  one  most 
commonly  followed  in  the  explanation  of  hygiene,  and  which  is 
equally  well  adapted  to  the  study  of  morbific  causes. 

A.  Circumfusa*  In  certain  circumstances  gases  unfit  for  re- 
spiration are  introduced  into  the  air  passages ;  nitrogen,  the  pro- 
toxide of  nitrogen  and  hydrogen  have  been  inhaled  by  chemists 
in  order  to  ascertain  their  effects  on  the  animal  economy.  They 
produced  a  mild  asphyxia  very  different  from  that  caused  by  the 
deleterious  gases.  These  last  are  sometimes  found  accumulated 
accidentally  in  certain  places  where  the  external  air  penetrates  with 
difficulty ;  as  in  drains,  sewers,  mines,  certain  work-shops,  facto- 
ries, and  in  some  thermal  establishments.  Carbonic  acid  gas  and 
carburetted  hydrogen,  which  are  disengaged  by  the  combustion  of 
charcoal,  may  become  mixed  with  the  air  in  sufficient  quantity  to 
asphyxiate  the  persons  who  breathe  them.  The  same  is  true  of 
the  gases  which  escape  from  animal  matters,  particularly  excrement 
in  a  state  of  putrefaction,  in  a  closed  vault,  by  which  asphyxia  is 
quickly  produced.  This  accident,  to  which  the  workmen,  who 
are  employed  in  clearing  privies  are  exposed,  is  occasioned  by  a 
gas  long  known  as  sulphuretted  hydrogen,  and  which  seems  most 
commonly  composed  of  hydro-sulphuric  acid,  hydro-sulphate  of 
ammonia  and  nitrogen.  Carbonic  acid  gas  accumulated  in  the 
lowest  part  of  certain  caverns,  (as  in  the  Grotto  del  Cane,  for  in- 
stance) is  in  that  situation  several  feet  in  depth ;  if  a  man  enter, 
he  is  above  the  level  of  the  deleterious  gas,  but  a  child  would  be 
asphyxiated,  like  the  animals  which  are  introduced  for  experiment. 

Putrid  and  malignant  fevers  have  at  times  raged  epidemically 
during  the  disinterment  of  a  large  number  of  bodies :  the  town  of 
Saulieu,  in  1773,  presented  a  sad  example  ;f  and  long  previously, 
an  epidemic,  gangrenous  fever  had  been  observed,  J  produced  by 
tainted  air  after  contagious  disease  among  animals,  where  great 
numbers  of  their  bodies  remained  unburied  and  infected  the  at-- 
mosphere. 

Vegetable  emanations  are  occasionally  the  determining  causes  of 
disease.  Air  charged  with  the  odorous  principle  of  the  hyacinth, 
the  lily,  the  orange  blossom,  the  narcissus,  causes  headache,  nau- 
sea, dizziness,  and  sometimes  even  fainting,  especially  in  small  and 
warm  apartments. 

A  very  high,  or  exceedingly  low  temperature  of  the  atmosphere 
is  a  determining  cause  of  many  affections.  Individuals  exposed  to 
severe  cold  have  often  been  observed  to  die  with  symptoms  which 
might  be  ascribed  to  asphyxia  or  to  strong  cerebral  congestion; 

*  Properly  speaking,  morbific  agents,  diffused  in  the  atmosphere,  act  only  by 
their  introduction  into  our  organs,  and,  thus  considered,  should,  perhaps,  be  ranked 
with  the  ingesta ;  but  it  has  not  been  deemed  proper  to  depart  from  the  classifica- 
tion generally  adopted. 

Maret,  Usage  cTenterrer  les  morts  dans  les  eglises.     Dijon,  1775. 

|  De  recondita  febrium  rcmitt.  ac  mtermitt.  natura. 


ETIOLOGY.  23 

freezing  of  a  portion  of  the  body  is  at  such  a  time  a  yet  more  fre- 
quent occurrence.  The  grave  symptoms  caused  by  a  very  elevat- 
ed temperature  have  also  been  referred  by  most  physicians  to  apo- 
plexy or  asphyxia ;  but,  from  the  researches  of  some  authors,  and 
those  of  J.  J.  Russel  in  particular,  it  seems  that  the  special  action 
of  heat  is  a  determination  towards  the  thoracic  organs,  causing  vi- 
olent congestion,  frequently  terminating  in  death.* 

A  very  brilliant  light  suddenly  flashing  upon  the  eye,  or  an  ex- 
ceedingly loud  noise,  may  produce  blindness,  or  deafness. 

A  violent  discharge  of  electricity  diffused  through  the  air,  or  col- 
lected by  apparatus,  has  caused  in  some  persons  sudden  death,  in 
others,  incurable  tremor,  stupor,  or  partial  paralysis. 

B.  Among  the  applicata  a  great  number  of  determining  causes 
exist.     Those  bodies  which  inflict  bruises,  and  pointed  and  cutting 
instruments,  are  the  most  common  causes  of  all  the  wounds  to 
which  man  is  exposed.  Falls,  in  which  the  human  body  strikes  with 
the  impetus  it  has  received,  against  surfaces  more  or  less  resistant, 
give  rise  to  diseases,  Analogous  to  those  produced  by  vulnerary 
agents. 

In  the  same  class  with  these  latter  must  be  placed  ligatures, 
which,  in  addition  to  their  hindrance  of  free  circulation,  may  pene- 
trate into  the  tissues  when  strongly  drawn,  and  asphyxiate  when 
applied  over  the  course  of  the  trachea. 

Immersion  in  a  liquid  has  a  similar  eifect  by  preventing  the 
ingress  of  air.  Incandescent  bodies,  and  boiling  liquids  placed 
in  contact  with  our  flesh  either  inflame  or  cause  gangrene,  ac- 
cording to  their  degree  of  power.  Solid  or  liquid  caustics,  acids, 
alkalies  and  salts,  act  in  an  analogous  manner  ;  some  of  these  sub- 
stances, as  corrosive  sublimate  and  arsenical  preparations,  may  be 
absorbed  at  the  surface  of  the  body  at  the  same  time  that  they  act 
locally  as  caustics ;  they  may  likewise  be  conveyed  into  the  in- 
ternal organs  and  give  rise  to  the  phenomena  of  poisoning.  In  the 
same  series  may  also  be  placed  the  acrid  topical  agents,  whether 
rubefacient  or  vesicant,  as  the  flower  of  mustard,  the  powder  of 
cantharides,  the  bark  of  the  Daphne  Mezereum,  etc.,  etc. 

C.  Ingesta.     Substances   introduced  into   the  interior  of  the 
body,  become  frequently  the  determining  causes  of  disease.     The 
poisons  belong  almost  wholly  to  this  class.     By  poisons  are  under- 
stood, according  to  Mead,  all  those  substances  which,  in  minute 
doses,  are  capable  of  producing  great  changes  in  living  bodies. 
We  prefer,  with  Mahon,  to  give  the  name  to  those  only  which  are 
destructive  of  life. 

Formerly,  poisons  were  divided  into  mineral,  vegetable  and  ani- 
mal. M.  Orfila  has,  with  reason,  considered  it  more  convenient  to 
class  them  according  to  their  mode  of  action  upon  the  economy, 
rather  than  after  the  particular  natural  kingdom  to  which  they 

*  Encycl.  des.  Sciences  Medicales  p.  235. 


24  ETIOLOGY. 

belong.  Consequently,  he  has  divided  them  into  four  classes, 
according  to  their  properties,  viz.,  irritating,  narcotic,  narcotico- 
acrid  and  septic.  Irritating,  corrosive,  escharotic  or  acrid  poisons, 
according  to  their  strength,  simply  inflame  or  completely  disorgan- 
ize the  part  to  which  they  are  applied.  Narcotic  poisons,  such 
as  opium,  the  solanacese,  etc.,  act  in  an  entirely  different  manner : 
their  operation  is  particularly  upon  the  brain,  whose  functions 
they  disorder  or  suspend,  and  they  have  but  little  effect  upon  the 
organs  with  which  they  are  in  immediate  contact.  Narcotico- 
acrid  poisons,  such  as  the  poisonous  mushrooms,  present  the  above 
two  modes  of  action  united.  Finally,  septic  poisons,  as  the  flesh 
of  animals  who  have  died  of  pestilential  diseases,  putrifying  animal 
matters,  and  certain  products  of  morbid  secretion,  bring  on  grave 
disease  of  an  adynamic  or  ataxic  form,  often  complicated  with 
gangrene,  and  most  usually  terminating  fatally.  Ergot,  which 
produces  gangrene  of  the  tissues,  must  be  classed,  for  this  reason, 
with  the  septic,  rather  than  with  the  narcotico-acrid  poisons. 

D.  There  are  but  few  determining  causts  among  the  excreta, 
the  gesta  or  the  percepta.  A  very  abundant  natural  haemor- 
rhage, particularly  if  menstrual,  may  bring  on  anaemia.  A  strong 
muscular  contraction  may  rupture  a  tendon,  or  break  a  bone  :  it 
is  often  the  determining  cause  of  hernia,  and  sometimes  of  dislo- 
cation. Very  powerful  moral  affections,  as  disappointed  love,  or 
nostalgia  in  adults,  and  chagrin  in  children,  are  sometimes  the  de- 
termining causes  of  a  species  of  hectic  fever.  A  deep-seated  pas- 
sion is  commonly  the  determining  cause  of  melancholy.  Despair, 
terror,  and  immoderate  joy,  have,  in  some  cases,  caused  sudden 
death.  There  are  some  diseases  which  may  become  the  deter- 
mining cause  of  certain  others.  Thus,  severe  parotiditis  has 
sometimes  produced  asphyxia ;  a  fracture  or  a  dislocation,  the 
formation  of  enormous  abscesses  in  the  cellular  tissue ;  perforation 
of  the  stomach,  rupture  of  the  galf-bladder,  the  urinary  bladder, 
the  uterus,  the  erosion  of  the  intestines  by  ulceration,  and  of  the 
pleura  by  softened  tubercle,  are  so  many  direct  causes  of  peritonitis 
or  of  pleurisy  almost  inevitably  fatal. 

Retention  of  frecal  matter  in  the  rectum,  has  sometimes  occa- 
sioned all  the  phenomena  of  intestinal  occlusion,  and  in  some  rare 
cases  has  caused  death,  especially  in  aged  patients. 

Finally,  the  presence  of  certain  parasitic  animals  in  the  human 
body,  may  be  added  to  the  above  determining  causes,  as  tsenia, 
the  oxyuris,  the  ascaris  lumbricoides,  hydatids,  etc.  Their  exist- 
ence does  not  always  produce  morbid  phenomena,  but  is,  in  itself, 
something  abnormal  as  regards  the  material  disposition  of  the 
parts.  Consequently,  it  constitutes  a  disease  which  will  always 
be  the  same  in  its  essence,  however  varied  may  be  its  form.  It  is 
the  same  with  inanimate  foreign  bodies,  introduced  into  our  organs 
by  the  natural  passages,  or  by  the  medium  of  a  wound;  although 
their  presence  may  occasion  no  disturbance  of  the  health,  we 
must,  nevertheless,  class  them  with  the  determining  causes,  be- 


ETIOLOGY.  25 

because  they  act  in  a  uniform  manner  ;  the  point  of  an  instrument 
or  a  ball  remaining  in  a  wound,  or  a  foreign  body  in  the  trachea, 
evidently  belong  to  this  class  of  causes. 

Specific  determining  Causes.  The  peculiar  character  of  these, 
as  was  mentioned,  is  the  production  of  diseases,  which  they 
alone  can  cause,  and  the  impossibility  of  explaining  them  by 
physical  or  chemical  laws. 

They  are  subdivided  into  two  distinct  series,  according  to  their 
mode  of  action  :  to  the  first,  belong  those  whose  effects  are  confined 
to  the  individual  who  is  exposed  to  their  influence;  to  the  second, 
those  morbific  agents,  which,  like  seeds,  reproduce  themselves  in 
the  course  of  diseases  to  which  they  give  rise ;  so  that  the  indi- 
vidual affected  by  them,  propagates  them  in  turn,  and  may  trans- 
mit them  to  other  persons ;  hence  arises  the  necessity  of  sub- 
dividing specific  causes  into  common  and  contagious. 

Common  specific  Causes.  This  series  consists  of  certain  me- 
tallic emanations,  some  of  the  poisons,  miasmatic  exhalations, 
and  the  venomous  secretions  of  animals. 

Those  who  work  in  lead,  painters,  smelters  of  metals,  those 
who  grind  colors  or  prepare  the  carbonate  and  red  oxide  of  lead, 
etc.,  are  subject  to  a  disease  known  as  lead  colic,  an  affection, 
which  differs  sufficiently  from  all  others  to  which  the  digestive 
tube  is  subject,  to  be  ranked  among  the  specific  diseases.  The 
colic  caused  by  copper,  on -the  contrary,  closely  resembles  the 
inflammation  resulting  from  external  causes.  Therefore,  notwith- 
standing the  similarity  between  these  two  kinds  of  colic,  we  must 
refer  the  action  of  copper  upon  the  economy,  to  common  determining 
causes,  while  the  preparations  of  lead  will  come  under  the  head 
of  specific  causes ;  in  like  manner  mercury  and  its  compounds 
belong  to  this  second  series,  in  consequence  of  their  entirely 
specific  influence  upon  the  mucous  membrane  of  the  mouth, 
(stomatitis,  or  mercurial  salivation.)  Strychnine  and  brucine, 
which  cause  tetanic  convulsions,  such  as  no  other  known  sub- 
stance can  produce,  may  with  propriety  be  classed  with  the 
specific  morbid  agents. 

Miasmatic  exhalations  constitute  another  group  of  morbific 
causes,  which  reason  would  induce  us  to  admit,  but  whose  exist- 
ence even,  has  not,  as  yet,  been  confirmed  by  physics  and  chem- 
istry, much  less  their  nature  and  effects  determined.  We  shall 
refer  them  to  two  classes,  according  to  their  origin. 

The  first  spring  from  the  decomposition  of  dead  vegetable 
and  animal  matter,  in  moist  or  marshy  places,  and  in  stagnant 
water.  These  are  styled  marsh  miasmata,  the  effluvia  of 
marshy  grounds :  if  it  is  borne  in  mind  that  intermittent  fevers 
prevail  habitually  throughout  the  regions  where  the  conditions 
which  cause  such  decomposition  exist;  that  these  fevers  make 
their  appearance  towards  the  end  of  summer,  when  the  receding 
water  has  exposed  its  basin,  formed  chiefly  by  the  remains  of  de- 
caying substances;  if  it  be  remembered  that  these  affections  have 
3 


26  ETIOLOGY. 

always  disappeared  upon  the  drying  up  of  the  marshes  ;  that  they 
show  themselves  only  momentarily  in  most  of  those  places  where 
pools  of  water  are  accidently  formed  ;  if  we  notice  that  they  are 
very  frequent  and  exceedingly  grave  in  the  localities  nearest  to 
standing  water,  and  become  more  rare  and  less  severe  in  propor- 
tion as  we  remove  farther  from  such  places  ;  finally,  if  we  regard 
the  influence  which  the  winds  in  the  neighborhood  of  marshes 
have  upon  their  development,*  we  cannot  but  admit  the  existence 
of  these  miasmata,  and  the  part  which  they  play  in  the  produc- 
tion of  intermittent  fevers.  Our  authority  for  ranking  the  marsh 
miasmata  among  the  specific  causes,  becomes  the  higher,  from  the 
fact  that  the  specific  character  of  the  diseases  which  they  produce, 
is  demonstrated  by  the  specific  character  of  their  remedy.  There 
cannot  be  a  specific  remedy,  except  for  those  diseases  which  recog- 
nize one  and  the  same  cause. 

The  other  species  of  miasmatic  exhalations  is  derived  from  liv- 
ing beings,  healthy  or  otherwise,  but  chiefly  from  those  diseased, 
when  collected  in  too  large  numbers  in  confined  places. 

The  peculiar  developing  causes  of  infectious  disease  most  often 
exist  united,  on  board  vessels,  in  prisons,  camps,  hospitals,  and  be- 
sieged cities,  and  these  are  the  conditions  which  cause  a  great 
number  of  diseases  to  rage  with  the  most  intensity ;  they  have 
been  described  as  putrid,  malignant  and  pestilential  affections. 
Almost  all  of  them  belong  to  the  different  kinds  of  typhus  and  to 
dysentery. 

By  general  agreement,  they  are  deemed  to  be  owing  to  the  alter- 
ation of  the  air  by  the  miasmata,  and  to  the  infection  of  the 
economy  by  it  when  thus  vitiated ;  by  infection  is  understood  the 
action  exercised  by  these  causes,  and  the  resulting  diseases  are 
termed  infectious. 

Venomous  secretions  must  also  be  classed  among  the  specific 
causes  of  disease.  These  are  peculiar  to  certain  species  of  ani- 
mals, and  serve  as  their  natural  means  of  attack  and  defence : 
when  deposited  by  the  animal  secreting  them,  in  the  wounds 
which  it  inflicts,  they  occasion  the  same  sort  of  affection  in  every 
instance.  The  viper,  the  wasp,  and  the  bee,  in  our  climate,  are 
the  only  creatures  provided  with  apparatus  fitted  for  the  secretion 
and  deposition  of  these  poisons.  In  warmer  climates,  the  scor- 
pion and  various  kinds  of  serpents  possess  far  more  deleterious 
qualities.  Venom  differs  from  virus  in  many  respects.  The  latter, 
as  we  shall  hereafter  see,  is  only  produced  accidentally,  by  diseased 
individuals;  the  formation  of  venom,  on  the  contrary,  is  continual, 
and  is  not  connected  with  any  functional  disturbance  :  virus  acts 
slowly,  and  reproduces  itself  in  those  affections  to  which  it  gives 
rise ;  the  effects  of  venomous  secretion  are  prompt,  and  not  trans- 
mitted from  the  one  who  suffers  by  them,  to  others. 

$  II.  Contagious  Principles.  There  is  a  certain  number  of 
diseases  which  may  be  transmitted  from  the  affected  individual 

*  Lancisi,  Senac,  Alibert. 


ETIOLOGY. 


27 


to  healthy  persons,  who  are  in  communication  with  him.  This 
transmission  of  disease  arising  usually  from  direct  or  indirect 
contact,  has  been  called  contagion;  and  the  epithet  contagions 
is  applied  to  diseases  thus  transmitted. 

We  are  ignorant  of  the  modus  operandi  of  contagion  ;  neverthe- 
less it  is  probable  that  it  takes  place  by  means  of  a  material  agent 
whose  existence  cannot  be  called  in  question,  although  it  escapes 
our  perceptions :  this  agent  is  called  the  contagious  principle  or 
virus. 

Although  not  recognized  by  our  senses,  the  contagious  princi- 
ples have  been  made  the  object  of  special  research  by  some  phy- 
sicians. The  following  is  the  opinion  of  most  pathologists  upon 
this  point. 

The  invisible  principle  which  causes  contagion,  is  usually 
enveloped  in  a  visible  substance,  as  mucus,  serous  fluid,  pus, 
(either  liquid  or  dried  into  crusts.)  and  the  matter  of  cutaneous 
transpiration.  These  different  substances  not  being  contagious  in 
themselves,  it  is  supposed  that  they  do  not  become  so,  in  certain 
cases,  except  by  mixture  with  this  subtle  and  unattainable  matter, 
which  is  the  agent  of  the  contagion.  At  all  events,  it  is  not 
impossible  that  the  pus  and  mucus  may  become  contagious  in 
themselves,  by  reason  of  the  alteration  effected  in  their  essential 
nature. 

However  this  may  be,  the  following  are  the  chief  characteristics 
of  contagious  principles : 

By  means  of  a  constant  series  of  morbid  phenomena,  they  all 
reproduce  principles  similar  to  themselves,  and  capable  of  causing 
the  same  effects.  They  maybe  multiplied  ad  infinitum,  by  means 
of  this  secondary  development,  so  long  as  they  meet  with  bodies 
capable  of  fully  receiving  their  action.  Indeed,  we  doubt  the  ex- 
istence of  any  virus  whose  contagious  properties  become  extinct 
after  the  second  transmission,  as  some  have  endeavored  to  prove 
in  regard  to  rabies  ;  nevertheless,  we  do  not  hesitate  to  admit  that 
some  kinds  of  virus,  by  continual  reproduction,  appear  to  become 
enfeebled  in  their  action ;  for  example,  the  syphilitic  virus  and 
that  of  the  plague. 

Some  of  these  contagious  principles  destroy,  either  temporarily 
or  entirely,  in  the  individual  who  experiences  their  effects,  the 
susceptibility  of  being  again  affected ;  such  are  those  productive 

*  Hufeland  defines  contagion,  or  the  contagious  principle,  to  be  a  subtle  mat- 
ter which  insinuates  itself  into  the  living  body,  and  which  may  there  excite  a 
definite  form  of  disease.  The  marsh  miasmata  are,  according  to  him,  and  by  the 
above  definition,  contagious  principles,  as  well  as  the  variolous  and  syphilitic 
virus.  He  admits  two  sorts  of  contagion,  the  living  and  the  dead.  "  The 
first  is  produced  by  a  living  body ;  it  may  occur  in  all  those  diseases  where 
the  humors  have  acquired  a  high  degree  of  putridity,  and  when  there  is  a 
specific  change  in  the  state  of  the  secreting  organs,  as  also  in  that  of  the 
humors  which  they  secrete,  as  in  measles,  scarlatina,  dysentery,  etc.  The 
other  sort  of  contagion,  is  that  derived  from  the  exhalations  of  inanimate 
bodies  ;  such  are  the  marsh  miasmata,  the  foul  air  which  causes  catarrhal 
fevers,  etc. 


28  ETIOLOGY. 

of  typhus,  small-pox,  scarlatina  and  measles :  others  have  seemed 
to  increase  rather  than  diminish  this  liability  to  renewed  attacks : 
the  syphilitic  virus  is  one  of  these.  In  other  words,  some  conta- 
gions diseases  attack  the  same  person  only  once  during  life ;  others, 
which  are  the  exception,  reappear  at  the  end  of  some  years; 
finally,  others  occur  in  those  who  have  before  been  affected  by 
them,  more  readily  than  in  those  who  had  previously  escaped  their 
effects. 

It  is  supposed  that  a  certain  proportion  of  the  contagious  princi- 
ples are  produced  without  cessation  during  the  entire  course  of  the 
disease,  while  others  only  arise  during  a  certain  part  of  it ;  but  this 
opinion  is  not  yet  sufficiently  proved. 

The  different  modes  of  contagion  have  been  likewise  the  object 
of  particular  research  ;  it  may  be  immediate,  or  communicated  by 
an  intermediate  body. 

Contagion  is  immediate  when  its  principle  is  directly  transmit- 
ted from  the  person  who  originates  it  to  the  one  who  receives  it 
and  experiences  its  effects  ;  this  immediate  transmission  may  occur 
in  many  ways  :  1st,  by  remaining  in  the  sick  room  when  the  air 
is  charged  with  contagiou's  principles,  as  appears  to  be  the  case  in 
the  transmission  of  typhus  and  perhaps  of  variola.  2d.  By  actual 
contact,  as  is  observed  in  most  diseases  of  this  character.  3d.  By 
still  closer  contact,  as  in  the  transmission  of  pestilential,  vaccine 
and  syphilitic  virus,  which  are  inert  upon  the  sound  skin,  and 
cannot  be  communicated  except  the  epidermis  has  been  previously 
removed  or  destroyed,  or  the  virus  deposited  upon  a  mucous  mem- 
brane. 4th.  Immediate  communication,  also,  may  be  effected  by 
means  of  the  remains  of  animals  destroyed  by  the  disease  which 
engenders  the  contagion :  it  is  in  this  way  that  the  malignant 
pustule  is  communicated  to  those. who  dress  the  skins,  or  handle 
the  wool  of  such  animals,  &c. 

Mediate  contagion  arises  through  the  agency  of  substances 
which  have  been  in  contact  with  the  patient's  body,  as  his  clothes, 
and  the  various  utensils  employed  about  him.  It  has  been  remarked 
that  among  the  substances  which  most  readily  receive  and  transmit 
contagion,  woollen,  silk,  cotton  and  linen,  hold  the  first  rank;  a 
strong  affinity  for  these  materials  has  been  ascribed  to  the  conta- 
gious principles,  which  are  retained  by  them  a  long  while,  espe- 
cially when  kept  from  the  air.  Those  holding  communication 
with  the  sick  may  transmit  contagion  without  being  themselves  af- 
fected ;  and  flying  insects,  alighting  in  turn  upon  the  patients  and 
upon  healthy  individuals,  have  been  supposed  to  carry  to  the  latter 
the  virus  which  they  had  drawn  from  the  former. 

The  circumstances  favoring  contagion,  or  the  action  of  contagious 
principles,  have  been  carefully  examined.  It  is  considered  highly 
important  that  the  contagious  principle  be  of  recent  origin  ;  its 
power  diminishes  gradually  in  the  course  of  time  ;  for  instance,  it 
has  been  proved  by  numerous  experiments,  that  the  pus  of  variola, 
after  the  lapse  of  a  year,  becomes  less  energetic,  and  at  the  end 
of  three,  is  no  longer  contagious.  Hildenbrand  supposed  that  the 


ETIOLOGY.  29 

contagious  principle  of  typhus  did  not  exist  beyond  three  months, 
because,  according  to  him,  no  epidemic  typhus  is  reproduced  after 
that  lapse  of  time,  without  the  concurrence  of  new  causes. 

Temperature  also  has  a  great  influence  in  facilitating  the  trans- 
mission of  contagious  diseases  ;  the  degree  of  heat  peculiar  to  the 
human  body  seems  most  favorable  to  contagion,  and  the  nearer  the 
atmospheric  temperature  approaches  this  standard,  the  more  easily 
are  contagious  diseases  propagated.  The  sudden  disappearance 
of  pestilential  disease  when  the  temperature  is  below  freezing, 
has  led  to  the  supposition  that  the  contagious  principle  was 
susceptible  of  congelation.  It  has  also  been  thought  that  these 
principles  might  be  destroyed  or  burned,  as  it  were,  by  extremely 
elevated  temperature ;  arid  those  physicians  who  enumerate  yellow 
fever  among  the  contagious  diseases,  have  supported  the  theory  of 
the  decomposition  of  virus  by  heat,  by  the  fact  of  the  sudden  cessa- 
tion of  that  disease  in  the  torrid  zone,  when  the  atmospheric  heat 
attains  an  unusual  degree  of  intensity.  M.  Bulard  has  observed 
the  same  in  regard  to  the  plague  of  the  East.  The  frequency  of 
typhus  in  winter  and  its  greater  violence  at  that  season,  seem  to 
invalidate  the  assertion  that  we  have  lately  made,  viz.,  that  a  tem- 
perature approaching  that  of  the  human  body  would  be  the  most 
favorable  for  the  transmission  of  contagious  diseases.  But  if  we 
reflect  that  the  number  of  sick  soldiers  is  much  greater  during 
winter  campaigns,  and  that  the  cold  weather  renders  it  indispensa- 
ble to  quarter  them  in  places  partially  or  entirely  closed,  where  in 
a  short  time  they  become  crowded,  we  shall  understand  that  if  epi- 
demic typhus  is  more  frequent  and  destructive  in  cold  and  wet 
seasons,  it  is  not  owing  to  the  cold,  but  to  the  concurrence  of  those 
injurious  circumstances  which  have  just  been  mentioned.  Still 
farther,  it  has  been  remarked  that  dampness,  absence  of  light,  and 
animal  emanations  favor  the  transmission  of  contagious  disease. 

Besides  these  general  circumstances  which  assist  the  action  of 
contagious  principles,  there  is  a  certain  number  which  are  peculiar, 
and  which  exercise  the  same  influence ;  such  are  youth  and  adult 
age,  an  impressible  and  delicate  constitution,  want  of  food,  absti- 
nence from  alcoholic  drinks  in  persons  who  have  habitually  used 
them ;  the  weakness  accompanying  convalescence,  fear,  discour- 
agement, terror,  errors  in  diet,  excessive  evacuations,  and  the  state 
of  sleep. 

Man  is.  almost  constantly,  the  source  which  begets  and  perpetu- 
ates the  greater  part  of  the  contagious  principles  with  which  we 
are  acquainted.  There  are,  however,  some  which  seem  not  to  be 
spontaneously  developed  in  him,  but  to  be  always  transmitted  by 
animals  ;  such  are  rabies,  glanders,  and  the  vaccine  disease. 

Among  contagious  diseases,  or  those  considered  as  such,  there 

are  several  which  originated  upon  this  continent,  typhus  fever  and 

the  itch  are  examples  ;  there  are  others  which  have  been  imported  ; 

variola,  scarlatina  and  measles  originated  apparently  in  Asia  ;  the 

3* 


30  ETIOLOGY. 

plague,  in  Asia  or  Africa ;  syphilis  and  yellow  fever  were  proba- 
bly brought  among  us  from  America.* 

The  primitive  formation  or  generation  of  contagious  principles 
is  shrouded  in  great  obscurity.  Some  physicians  think  that  having 
been  generated  at  one  particular  time,  they  have  ever  since  been 
reproduced  by  means  of  transmission  only.  This  opinion  is, 
however,  inadmissible.  It  is  true  that  the  conditions  under  which 
many  of  these  principles  are  developed,  are  unknown ;  but  still 
we  must  allow  that  they  can,  and  must  be,  reproduced  by  a  con- 
currence of  causes  resembling  those  which  first  brought  them  into 
being.  The  history  of  European  typhus,  and  its  reproduction 
under  the  action  of  well  known  circumstances,  exemplify  this 
opinion,  and  lead  us  to  suppose  that  there  must  be  some  analogy 
in  the  development  of  exotic  poisons,  as  those  of  the  plague, 
variola  and  syphilis. 

But  if,  as  everything  would  induce  us  to  think,  these  different 
sorts  of  virus  did  not  originate  in  Europe,  if  they  were  first 

*  Were  not  the  incompatibility  of  this  assertion  with  the  date  of  the  first  appear- 
ance of  syphilis,  in  Europe,  sufficient  to  prevent  its  incorporation  into  the  present 
work,  even  in  the  slightly  qualified  terms  used  by  the  author,  it  would  seem  that 
the  concurrent  testimony  of  the  best  authorities  of  more  remote  times  as  well  as  of 
our  own,  would  have  rendered  its  insertion  impossible.  Jourdan,  long  since,  suf- 
ficiently disproved  the  opinion  of  the  American  origin  of  syphilis,  and  by  an  elabo- 
rate comparison  of  dates  showed  the  utter  impossibility  of  its  having  been  imported 
into  Europe,  according  to  our  author's  supposition.  But  it  is  unnecessary  to  re- 
peat his  widely  known  observations,  or  even  the  apparently  well-founded  opinions 
of  many  others  who  date  the  origin  of  the  disease  as  far  back  as  the  days  of  Old 
Testament  narration  ;  among  these  are  B.  Bell  andM.  Cazenave,  cited  by  Grisolle 
in  his  late  work  upon  Internal  Pathology,1  who  himself  also,  although  he  considers 
the  question  undecided,  evidently  leans  toward  the  ancient  origin  of  the  disease, 
and  mentions  a  statute  of  Jeanne  the  First,  Queen  of  the  Sicilies,  relative  to  medi- 
cal inspection  of  prostitutes  diseased  in  their  genital  organs  ;  this  was  in  1347, — 
and  no  author  has  pretended  that  the  disease  was  imported  before  the  arrival  of 
Columbus  and  his  companions  from  America  in  1493.  Oviedo,  one  of  the  cham- 
pions of  the  importation  doctrine,  mentions  its  appearance  in  America  in  1498, 
which  is  after  its  manifestation  at  the  siege  of  Naples,  by  Charles  VIII. ,  the  con- 
quest of  which  city  was  effected  in  1495.  Some  have  asserted  its  existence  at 
Paris,  in  1494.  It  is  likewise  stated  to  have  been  "raging"  at  Rome,  and  in 
other  parts  of  Italy  in  June,  1493,  and  even  supposing  the  possibility  of  its  having 
been  carried  to  that  country  by  the  followers  of  Columbus,  who  arrived  from 
America  only  two  months  previously  to  the  latter  date,  is  it  reasonable  to  suppose 
that  it  could  have  been  raging  in  various  parts  of  the  country  so  soon  ?  Besides, 
the  importation  by  these  men  in  that  space  of  time,  is  not  proved.  Hunter,  Spren- 
gel,  Pearson  and  Bacot,  among  others,  have  lent  the  powerful  influence  of  their 
names  and  arguments  against  this  doctrine.  M.  Cazenave,  of  all  modern  writers, 
perhaps,  uses  the  strongest  language,  and  furnishes  the  most  irresistible  proof  in  re- 
gard to  what  he  considers  the  "fable  "  of  the  American  origin  of  syphilis.  Some 
account  of  his  views  may  be  found  in  the  British  and  Foreign  Medical  Review,  for 
April,  1847,  pp.  346,  347.  Why  is  it  not  reasonable  to  suppose  that  promiscuous 
copulation  in  any  country  and  amongthe  most  cleanly  people,  might  engender  disease 
of  the  genital  organs  ?  But  was  it  less  likely  to  occur  among  the  dirty  and  depraved 
soldiers  of  a  European  army,  and  the  luxurious  profligates  of  the  higher  classes, 
than  among  the  inhabitants  of  America,  simple  in  their  habits,  and,  as  it  were,  only 
on  the  borders  of  civilization  ?  —  TRANS. 

1  Path.  Int.,  vol.  ii.  p.  23.    De  La  Syphilis  ou  Maladie  Venerienne. 


ETIOLOGY.  31 

generated  in  other  countries  and  with  an  assemblage  of  conditions 
nonexistent  among  us,  we  must  suppose,  whenever  we  observe 
them,  that  they  are  owing  to  contagion,  even  when  we  cannot  point 
out  the  individual  from  whom  it  emanated. 

Among  exotic  poisons,  many  are  acclimated  on  our  con- 
tinent; they  appear  there  without  interruption,  and  produce  at 
intervals,  (doubtless  with  the  concurrence  of  favorable  atmospheric 
conditions,)  epidemics  of  greater  or  less  severity  :  variolic  virus 
and  that  of  scarlatina  and  measles,  are  examples.  Other  conta- 
gious diseases,  or  those  so  reputed,  as  the  plague  and  yellow  fever, 
manifest  themselves,  as  it  were,  only  momentarily  :  they  usually 
disappear,  after  having  committed  their  ravages  for  some  seasons. 

Linnceus  published,  in  the  Amenites  Academiques,  a  dissertation 
wherein  he  endeavors  to  establish  that  all  contagious  diseases  are 
owing  to  animalcules,  which,  by  being  transported  from  the  infect- 
ed to  the  healthy,  transmit  the  disease,  which  is  but  the  effect  of 
their  presence.  The  foundation  of  this  theory  may  be  seen  in  the 
work  above  mentioned ;  some  very  curious  details,  especially,  will 
be  found,  relative  to  the  form  and  habits  of  the  acarus  dysen- 
terice,  but  these  are  foreign  to  our  purpose.  The  interesting 
researches  which  have  since  been  made,  have  firmly  established 
this  opinion,  as  regards  the  itch;  the  existence  of  the  acarus  scabiei, 
is  now  demonstrated ;  but  there  is  no  reason  for  supposing  any- 
thing analogous  in  other  contagious  diseases. 

Such  are  the  chief  morbific  causes,  which,  brought  into  action 
upon  the  economy,  invariably  produce  the  same  effects.  Their 
mode  of  action  will  be  hereafter  considered. 


ARTICLE    SECOND. 
Predisposing  Causes. 

ACCORDING  to  the  course  generally  agreed  upon  in  the  methodical 
study  of  all  sciences,  we  have  thought  proper  to  speak  first  of  the 
most  apparent  causes  of  disease ;  at  present,  we  intend  to  examine 
those  which  are  the  least  so,  commencing  with  those  called  pre- 
disposing, which,  as  we  have  said,  act  by  degrees  upon  the  econ- 
omy and  prepare  it  for  various  affections.  Their  action  is  almost 
always  obscure  and  often  questionable.  All  that  we  shall  say 
therefore,  upon  this  action,  must  be  considered  as  a  collection  of 
generally  admitted  opinions  on  the  subject,  rather  than  the  con- 
sequence of  facts  rigorously  observed,  or  the  expression  of  our 
own  conviction. 

Some  of  the  predisposing  causes  extend  their  action  to  a  great 
number  of  individuals  at  once,  as  to  the  entire  population  of 
a  city,  a  province  or  an  empire;  sometimes  to  large  collections 
of  men  encamped,  or  in  navies,  hospitals  and  prisons ;  they  favor 
the  development  of  similar,  or  analogous  affections  in  all  who  are 


32  ETIOLOGY. 


exposed  to  their  influence :  we  shall  style  these,  general  predis- 
posing causes.  Others  act  only  upon  isolated  individuals:  these 
may  be  called  individual  predisposing  causes.  The  principal 
morbific  causes  belonging  to  these  two  series,  will  now  be  briefly 
enumerated. 


SECTION    FIRST. 

General  Predisposing  Causes. 

The  general  predisposing  causes  are,  for  the  most  part,  diffused 
in  the  atmosphere,  or  arise  from  certain  local  conditions. 

Atmosphere.  The  air  has  a  very  decided  influence  upon  the 
human  body:  this  is,  however,  limited,  and  it  does  not  at  all  follow 
that  the  state  of  the  economy  should  be  entirely  subordinate  to 
that  of  the  atmosphere,  as  some  physicians  have  pretended.* 

The  frequent  changes  of  the  atmosphere  are  occasional  rather 
than  predisposing  causes  of  disease.  It  is  more  particularly,  when 
for  a  long  time  in  the  same  state,  that  the  air  seems  to  produce  modi- 
fications in  the  human  body,  from  which  result  various  predispo- 
sitions to  disease.  A  cold  and  dry  air  predisposes  to  deep-seated 
inflammations,  and  active  haemorrhage,  and  gives  to  the  greater 
part  of  acute  affections  which  may  be  developed,  their  character,  or 
what  has  been  called  inflammatory  nature.  A  warm  and  dry  air 
hastens  the  development  of  superficial  inflammations,  as  erysipe- 
las, and  the  exanthemata,  and  often  gives  to  acute  disease  the 
form  termed  bilious.  Aifections  of  the  mucous  membranes  and 
those  called  adynamic,  prevail  under  the  influence  of  a  warm  and 
moist  air :  catarrh,  scurvy  and  rheumatism  occur  more  particularly 
when  the  atmosphere  has  for  a  long  while  been  moist  and  cold. 

In  our  climate,t  the  north  and  east  winds  are  almost  always 
dry  and  cold;  the  south-east  dry  and  warm;  the  south-west  is 
of  a  warm  and  moist  temperature ;  the  north- west  is  cold  and 
moist.  The  influence  of  these  winds  in  the  production  of  dis- 
eases is  the  same  as  that  of  the  different  qualities  to  which  they 
correspond. 

Air  which  is  riot  renewed,  quickly  becomes  vitiated,  as  may  be 
remarked  in  confined  apartments,  especially  in  dungeons  and 
subterranean  passages.  Man  cannot  remain  long  in  such  places 
without  experiencing  injurious  effects ;  his  functions  languish,  his 

*  Tails  est  sanguinis  dispositio,  quails  est  aer  quern  inspiramus.  — RAMAZZINI, 
de  Constitutione,  anni  1691. 

f  The  reader  will  of  course  perceive  the  necessity  of  adapting  the  above 
remarks  in  regard  to  the  influence  of  the  winds,  to  "  our  climate  ;"  our  differ- 
ent position,  as  respects  the  ocean,  changing  wholly  the  nature  of  that  influence  : 
as  for  instance,  the  north  and  east  winds  with  us,  are  almost  uniformly  moist 
and  cold  ;  the  term  "  dry  "  is  almost  never  applicable  to  our  south-east  wind, 
although  it  may,  sometimes,  be  "  warm  ;  "  our  south-west  winds  are  warm  and 
dry,  and  our  north-west,  cold  and  dry. — TRANS. 


ETIOLOGY.  33 

constitution  becomes  enfeebled,  and  chronic  affections  of  different 
kinds  are  developed.  The  stagnation  of  the  air  in  the  ravines 
of  the  Valais,  appears  (from  the  researches  of  Fodere)  to  be  the 
principal  cause  of  the  frequency  of  goitre  in  that  country. 

Considerable  variations  in  atmospheric  pressure  may  also  be 
considered  as  causes  of  disease.  Examples  are  cited  of  ocular 
haemorrhage,  of  epistaxis  and  haemoptysis  determined  by  a  dimi- 
nution of  the  weight  of  the  air,  produced  either  by  a  change 
supervening  in  the  atmosphere,  or  because  the  individual,  being 
elevated  into  a  higher  region,  was  submitted  to  the  pressure  of  a 
smaller  column  of  air.  The  diminution  and  increase  of  atmos- 
pheric pressure  have  also  been  declared  equally  powerful  causes 
of  cerebral  congestion  and  apoplexy. 

Deprivation  of  light  disposes  to  anasarca,  to  scurvy  and  scrofu- 
la, and  always  gives  rise  to  a  sort  of  etiolation,  similar  to  that 
produced  by  the  same  cause  in  vegetables. 

The  researches  of  M.  Edwards  also  go  to  prove  that  the  action 
of  light  is  necessary  for  the  development  of  the  body,  and  that 
its  withdrawal  may  be  considered  one  of  the  external  causes 
productive  of  deformity  in  scrofulous  children.*  This  agrees  also 
with  the  generally  admitted  opinions  upon  the  etiology  of  these 
affections.  Hildenbrand  has  likewise  remarked  that  absence  of 
light  greatly  favored  the  contagion  of  typhus,  f 

Does  electricity  diffused  in  the  atmosphere,  aid  in  developing 
disease,  as  some  modern  physiologists  have  asserted?  Can  we 
admit  the  existence  of  a  nervous  fluid  analogous  to  galvanism  ? 
Does  it  follow  that  vital  power  is  increased  when  positive  elec- 
tricity is  in  excess ;  that  it  diminishes  when  negative  electricity 
is  most  abundant,  in  low  and  moist  localities,  before  storms,  in 
warm  seasons,  and  with  a  west  wind  ?  These  purely  hypotheti- 
cal opinions  are  not  suitable  for  present  discussion. 

As  Hippocrates  remarks,  all  diseases  may  manifest  themselves 
at  any  time  of  the  year ;  nevertheless,  the  natural  changes  which 
supervene  in  the  atmosphere,  by  reason  of  the  succession  of  sea- 
sons, influence  very  powerfully  the  development  of  many  among 
them.  This  influence,  which  has  been  recognized  from  the 
earliest  days  of  the  science,  has  been  confirmed  by  physicians  of 
every  age.  Hippocrates  remarked  a  uniform  character  among 
summer  diseases  ;  he  likewise  noticed  some  analogy  among  those 
of  winter,^  and  he  comprised  among  the  former,  the  complaints 
common  in  the  latter  half  of  spring  and  the  first  half  of  autumn ; 
and  in  the  second  class,  those  of  the  last  of  autumn  and  of  the 
early  spring.  In  our  climate,  more  resemblance  exists  between 
the  diseases  of  spring  and  of  the  months  preceding  and  following 
that  season,  than  between  those  of  summer  and  the  neighboring 

*  Influence  des  Agens  Physiques,  pp.  401  et  402. 
f   Typh.  conta. 
J  Aphor.  lib.  iii. 


34  ETIOLOGY. 

months ;  the  same  observation  applies  to  the  complaints  of 
autumn  and  winter,  and  those  of  spring  and  autumn  form  sepa- 
rate groups.  The  progress  of  the  former  is  more  rapid,  their  ter- 
mination more  complete,  their  duration  less ;  in  them,  relapse  is 
not  so  common,  and  remedies  are  more  efficacious.  The  develop- 
ment of  the  other  class  is  more  gradual,  their  continuance  far 
longer,  and  sequelae  of  a  bad  and  obstinate  nature  often  succeed 
them ;  they  do  not  yield  as  readily  to  treatment,  and  are  more 
easily  reproduced  after  momentary  suspension.  This  difference 
has  been  particularly  observed  in  intermittent  fevers,  vernal  or 
autumnal ;  but  it  is  by  no  means  a  rule  of  constant  application. 
In  our  climate,  the  number  of  grave  diseases  is  uniformly  more 
considerable,  and  the  mortality  greater,  in  spring  than  in  au- 
tumn. 

In  addition  to  the  above  marked  differences  which  these  two 
opposite  periods  of  the  year  cause  in  disease,  it  has  been  observed 
that  each  season  has,  in  like  manner,  a  less  noticeable,  but  still  an 
incontestible  influence.* 

Winter,  with  a  dry  atmosphere,  usually  predisposes  to  inflam- 
matory complaints,  active  haemorrhages  and  cerebral  congestions  ; 
when  wet,  to  affections  of  the  mucous  membranes  and  chronic 
discharges.  In  summer,  bilious  diseases,  cutaneous  exanthemata, 
cholera  morbus,  mental  alienation  and  various  other  neuroses, 
prevail.  Autumn  apparently  contributes  to  the  development  of 
mucous  and  rheumatic  affections,  dysentery  and  intermittent  fe- 
vers, which  are  more  frequent  at  this  season  than  at  any  other. 
Spring  almost  always  abounds  in  inflammations  of  the  throat  and 
chest,  and  in  haemorrhages,  etc. 

The  influence  of  the  moon,  and  fixed  stars,  upon  the  develop- 
ment of  disease  has  often  furnished  physicians  with  matter  for  dis- 
cussion. If  these  bodies  exert  no  action  upon  the  temperature  and 
moisture  of  the  air,  it  is  very  likely  that  they  have  none  upon  the 
animal  economy.  But  if,  as  many  natural  philosophers  have  as- 
serted, tides,  storms  and  the  course  of  the  winds  are  subject  to  the 
influence  of  lunar  changes,  the  moon  might  possibly  have  a  direct 
action  upon  the  economy ;  an  indirect  effect  might,  at  least,  be 
demonstrated. 

Localities.  There  is  no  part  of  the  earth  which  is  not  habitable 
by  man.  But  although  capable  of  inhabiting  every  place,  he  can- 
not escape  the  influence  which  is  thus  exerted  upon  his  constitution 
or  the  morbid  modifications  communicated.  In  southern  climates, 

*  Some  physicians,  supposing  they  had  observed  that  the  principal  changes 
caused  by  the  seasons  in  prevailing  diseases,  did  not  correspond  exactly  to 
the  divisions  of  the  common  year,  proposed  to  form  a  mtdical  year,  in  which 
spring  should  commence  on  the  twelfth  of  February  ;  summer  on  the  twelfth 
of  May  ;  autumn  in  August,  and  winter  in  November  ;  but,  as  there  is  no  regu- 
larity in  the  period  when  the  so-called  vernal  or  autumnal  diseases  appear, 
as  their  manifestation  even,  is  not  constant,  it  is  more  reasonable  to  continue 
the  usual  limits  to  each  great  division  of  the  year,  and  to  the  words  in  common 
use  their  general  acceptation. 


ETIOLOGY.  35 

tetanus,  yellow  fever,  and  many  diseases  wholly  unknown  at  the 
north,  prevail ;  in  the  opposite  latitudes,  inflammatory  affections 
are  very  frequent :  in  temperate  climes  a  greater  variety  of  disease 
exists.  In  dry  and  elevated  districts,  men  are  exceedingly  subject 
to  all  the  acute  affections ;  chronic  complaints,  on  the  contrary,  pre- 
vail in  low  and  wet  countries.  This  influence  of  elevated  position 
may  be  easily  verified  in  cities  built  both  on  high  and  low  ground ; 
in  the  upper  portion,  diseases  are  rare  and  of  very  rapid  progress ; 
in  the  lower,  they  are  more  frequent  and  tend  to  the  chronic  type. 

A  northern  or  eastern  exposure,  or  a  southern  or  western  one 
have  the  same  influence  in  the  development  of  disease,  as  the 
winds  blowing  from  either  of  these  directions.  (Page  32.) 

City  and  country  life  dispose  to  very  different  affections.  The 
neuroses,  scrofula,  rachitis  and  pulmonary  phthisis  are  far  more 
frequent  among  the  inhabitants  of  cities  than  among  those  residing 
in  the  country  ;  a  country  population  is  more  exposed  to  acute  dis- 
ease, and  chronic  affections  are  rare.  A  residence  in  hospitals, 
prisons,  vessels,  and  barracks  apparently  predisposes  to  dysentery, 
scurvy  and  different  kinds  of  dropsy. 

Change  of  abode  likewise  becomes  a  general  predisposing  cause 
for  sailors  and  soldiers  transported  far  from  their  country.  Lind 
compares  men  who  have  left  the  land  of  their  birth  to  vegetables 
transplanted  into  a  strange  soil ;  they  cannot  experience  the  new 
conditions  in  which  they  are  placed,  without  injury  to  their  health 
or  a  loss  of  vigor,  at  least  for  a  time.  The  masses  of  men  which 
are  transported  far  from  their  country,  the  European  troops  which 
go  to  another  continent,  are  often  smitten  by  more  or  less  severe 
disease,  evidently  owing  to  this  cause ;  for  these  diseases  not  being 
known  in  the  country  where  the  men  were  born,  they  would  have 
escaped  them  if  they  had  remained  there ;  of  such  is  the  yellow 
fever  which  destroys  Europeans  in  some  parts  of  America,  and 
which  has  never  been  observed  in  the  north  of  Europe,  above  the 
mouth  of  the  Gironde ;  and  abscess  of  the  liver,  so  rare  among  us 
and  so  common  in  some  parts  of  India. 

An  almost  constant  fact,  to  which  the  attention  of  physicians 
has  not,  perhaps,  been  sufficiently  directed,  is  the  good  health  on 
board  fleets  which  traverse  the  seas  without  making  any  port,  and 
which  is  singularly  in  contrast  with  the  diseases  that  afflict 
them  under  opposite  circumstances.  The  constant  change  of 
place  seems  useful  to  man  upon  the  ocean,  as  well  as  on  land ; 
voyages  generally  preserve  and  strengthen  the  health;  if  pas- 
sengers become  diseased,  it  is  almost  always  when  they  have  been 
stationary  for  a  certain  time  in  the  same  place. 

The  changes  brought  about  in  certain  situations  through  the 
agency  of  man,  as  the  clearing  of  forests,  or  the  cutting  of  canals, 
have  sometimes  produced  a  marked  effect  upon  the  sanatory  con- 
dition of  the  population. 

There  are  still  some  predisposing  causes  of  disease,  which  may 
act  simultaneously  upon  a  great  number  of  individuals,  and  which 
at  present  we  shall  only  mention,  because  they  act  most  com- 


36  ETIOLOGY. 

monly  upon  isolated  individuals,  and  thus  appertain  more  naturally 
to  the  individual  predisposing  causes.  Such  are  clothing,  food 
and  the  moral  affections. 

Wet  garments  suffered  to  remain  upon  the  body,  are  one  of  the 
chief  causes  of  rheumatism  and  dysentery  in  land  armies,  and  of 
scurvy  on  board  ship.  If  it  surprise  us  that  a  cause,  to  all  appear- 
ance the  same,  should  produce  different  effects  on  land,  and  at  sea, 
the  reason  of  this  difference  may  be  discovered  in  the  opposite 
qualities  of  rain  and  sea-water,  the  latter  of  which  contains  deli- 
quescent salts,  which  prevent  the  complete  drying  of  the  sailor's 
garments  and  keep  him  constantly  wet. 

Food  which  has  become  putrid,  salted  meat,  want  of  flour,  or 
of  fresh  vegetables,  and  bad  water,  are  all  general  causes  of  disease 
for  the  inhabitants  of  a  besieged  city}  or  for  men  in  large  num- 
bers on  board  a  fleet  or  in  camp. 

The  moral  affections,  which  are  the  same  for  the  whole  of  an 
army,  and  sometimes  for  all  the  inhabitants  of  a  city,  or  an  empire, 
may  be  considered  in  some  cases  general  predisposing  causes.  The 
influence  of  these  affections  upon  the  health  of  our  soldiers,  in  the 
disastrous  campaigns  of  1813  and  1814,  was  very  evident;  the 
number  of  diseases  increased  in  a  frightful  degree,  as  fortune  for- 
sook our  banners. 

Political  institutions,  and  the  more  or  less  advanced  state 
of  civilization  of  different  nations,  must  also  be  ranked  in  the 
number  of  the  general  predisposing  causes  of  many  diseases ;  it  is 
for  this  reason  that  in  free  countries,  among  enlightened  people, 
where  the  intellectual  faculties  are  most  active,  where  man  de- 
votes himself  to  the  study  of  the  sciences  and  arts,  to  commercial 
speculations  and  to  labor,  and  among  nations  often  distracted  by 
violent  political  commotions,  mental  alienation  and  hypochondria- 
sis  are  far  more  frequent  than  where  the  people  live  in  idleness, 
ignorance  or  slavery. 


SECTION  SECOND. 

Individual  Predisposing  Causes. 

Individual  predisposing  causes  are  much  more  numerous  than 
those  termed  general,  because  there  are  many  circumstances 
which  may  act  upon  isolated  individuals  and  cannot  be  common 
to  a  great  number ;  while  all  the  general  predisposing  causes,  as 
situation,  dwelling,  etc.,  are  also  individual  predisposing  causes. 

These  causes  being  very  numerous,  and  their  influence  in  pro- 
ducing disease  not  being  the  same,  we  shall  divide  them  into  two 
series.  In  the  first,  will  be  classed  the  various  conditions  peculiar 
to  each  individual,  as  birth,  age,  sex,  temperament,  constitution, 
habits,  profession,  degree  of  comfort  or  privation,  illness,  conva- 
lescence, health,  and  pregnancy ;  and  we  shall  designate  these 


ETIOLOGY.  37 

different  conditions  by  the  term  aptitudes,  since  they  dispose  the 
individuals  to  various  diseases,  rather  than  take  an  active  part  in 
their  production. 

In  the  second  series  will  be  enumerated  those  various  external 
circumstances,  which  predispose  with  more  or  less  energy  to  the 
development  of  disease. 

I.  APTITUDES. 

A.  A  descent  from  parents  affected  with  certain  diseases,  is  a 
condition  which  should  lead  us  to  fear  the  development  of  similar 
affections.  "  The  ailments  of  our  parents,"  said  Baillou,  "  are 
inherited  as  well  as  their  goods,  and  this  sad  inheritance  is  far 
more  certainly  transmitted  than  the  other."  Diseases  which  thus 
pass  from  father  to  child,  are  called  hereditary ;  sometimes,  so  to 
speak,  they  skip  one  generation  and  manifest  themselves  in  the 
grandchildren.  They  may  appear  in  every  child ;  but  usually,  only 
in  a  limited  number.  They  may  be  transmitted  by  either  father 
or  mother.  Cullen  has  observed  that  children  are  most  subject  to 
the  diseases  of  the  parent  whom  they  most  resemble. 

The  diseases  of  the  mother  are  perhaps  more  commonly  trans- 
mitted than  those  of  the  father,  not  only  because  there  is  certainty 
in  regard  to  the  maternity,  but  also  because  the  female,  whose 
part  in  the  act  of  conception  is  equal  to  that  of  the  male,  supplies 
from  herself  alone,  what  is  required  for  the  development  of  the 
foetus  during  its  entire  intra-uterine  existence,  and  also  nourishes 
it  from  her  own  substance  through  the  whole  period  of  nursing. 
It  is,  therefore,  natural  to  suppose  that  the  mother  has  a  greater 
influence  than  the  father  upon  the  child's  constitution,  and  upon 
its  predisposition  to  disease.  In  support  of  this  opinion,  let 
it  be  remembered  that  in  the  crossing  of  animals,  the  relative 
influence  of  the  two  sexes  is  quite  manifest :  the  mule,  which  is 
the  issue  of  the  mare  and  the  ass,  is  incomparably  larger  and 
stronger  than  the  product  of  an  opposite  cross. 

There  is  no  longer  any  dispute  in  regard  to  the  transmission  of 
diseases  from  parents  to  children,  considered  in  an  abstract  manner ; 
but  admitting  this  first  point,  discussions  arise  with  regard  to  the 
question  of  the  hereditary  nature  of  particular  diseases.  There 
could  be  no  doubt  on  this  point,  if  the  affections  were  such  as  show 
themselves  only  in  the  offspring  of  those  who  had  suffered  by 
them,  and  if  all  the  children  of  parents  so  affected  were  attacked 
without  exception ;  but  this  is  not  the  case.  On  the  one  hand, 
every  disease  susceptible  of  transmission  from  parents  to  children 
may  occur  from  other  causes,  and  on  the  other,  there  is  no  cause 
which  uniformly  affects  all  the  children  who  become  diseased: 
it  is  only  by  aid  of  exact  and  numerous  observations,  which  sci- 
ence does  not  yet  possess,  and  which  it  can  only  slowly  acquire, 
that  we  shall  be  able  to  appreciate  the  relative  frequency  of  a  dis- 
ease in  individuals  born  of  affected  parents,  and  in  those  whose 
4 


38  ETIOLOGY. 

parents  have  been  exempt  from  it,  and  thus  determine  how  far 
a  disease  is  hereditary.  r 

When  we  wish  thus  to  study  any  disease,  phthisis,  for  in- 
stance, we  must  seek  the  solution  of  the  problem  more  by  follow- 
ing the  course  of  the  children's  lives,  who  are  born  of  parents 
destroyed  by  this  disease,  than  by  going  back  to  the  complaints 
of  which  the  parents  died.  It  is,  indeed,  needless  to  examine 
whether  the  disease  may  be  developed  or  not  by  the  aid  of 
hereditary  predisposition  and  occasional  causes.  This  is  not  the 
question:  no  author  has  asserted  that  a  disease  susceptible  of 
transmission  from  father  to  child  could  not  be  developed  likewise 
by  other  causes.  The  real  question  is,  to  "determine  at  first,  if  such 
a  disease  is  transmitted  from  parents  to  children,  and  afterwards, 
how  frequently  this  happens.  It  is  then,  by  following  the  gener- 
ations, rather  than  by  tracing  them  back,  (if  we  may  be  allowed 
the  expression,)  that  the  question  of  hereditary  disease  must  be 
studied  and  definitely  decided.  We  are  convinced  that  by  follow- 
ing this  course  in  regard  to  pulmonary  phthisis,  results  will  be 
obtained,  proving  that  children  born  of  phthisical  parents,  die,  in 
a  great  proportion  of  cases,  of  the  same  disease.  It  is  not  so  easy 
to  say  what  would  be  the  result  of  similar  research  with  the 
intention  of  ascertaining  whether  cancer  is  hereditary.  In  the 
present  state  of  science,  it  appears  to  us  reasonable  to  allow, 
without  however  affirming  it,  that  individuals  born  of  cancerous 
parents,  are,  other  things  being  equal,  more  often  affected  with 
like  complaints  than  those  who  are  not  thus  connected. 

In  general,  diseases  which  are  developed  under  the  influence 
of  hereditary  predisposition,  are  manifested  at  an  earlier  age  than 
when  not  thus  transmitted.  It  has  been  remarked,  that  children 
born  of  consumptive  parents,  died  at  a  less  advanced  age  than 
their  parents,  and  often  before  they  were  old  enough  to  transmit 
this  unfortunate  predisposition. 

Reputed  hereditary  affections  are  exceedingly  various.  Some 
consist  in  an  evidently  vicious  conformation,  for  instance,  a 
diminution  or  increase  in  the  number  of  organs ;  others,  in  simple 
functional  disturbance  without  any  appreciable  lesion  of  the 
tissues,  as  blindness  or  deafness.  Some  are  congenital,  as  is 
occasionally  the  case  with  syphilis,  etc. ;  others,  and  by  far  the 
greater  number,  are  latent  for  a  longer  or  shorter  time  after  birth ; 
rachitis  until  the  second  or  third  year ;  scrofula  and  epilepsy 
appear  in  infancy ;  pulmonary  consumption  and  mental  alienation 
in  youth ;  gout  and  haemorrhoids  in  adult  age ;  apoplexy  still 
later.  In  some  families  hereditary  disease  is  developed  and  ter- 
minated, uniformly  at  the  same  period  of  life.  Montaigne,  whose 
ancestors  were  affected  with  gravel,  was  attacked  by  it  at  the 
same  age  as  his  father.  Some  practitioners  have  thought  that 
chronic  affections  only,  could  be  transmitted  from  parents  to  chil- 
dren; and  it  should  be  remembered  that  phthisis,  mania  and 
epilepsy  occupy  the  first  rank  among  hereditary  diseases.  Gout 
and  rheumatism,  however,  are  usually,  acute  diseases,  at  any  rate 


ETIOLOGY.  39 

in  their  first  attacks,  and  by  common  consent,  are  hereditary.  In 
some  families  it  has  also  been  observed  that  there  exists  a 
tendency  to  plethora  and  to  certain  inflammations. 

The  diseases  which  infants  exhibit  at  birth,  (maladies  de 
naissance, )  are  not  always  hereditary ;  those  affected  with  hydro- 
cephalus  or  spina  bifida,  die  soon;  they  cannot,  consequently, 
transmit  these  diseases,  and  for  the  same  reason  they  cannot  have 
inherited  them.  Still  farther,  it  has  been  remarked  in  certain 
cases,  that  all  the  children,  or  most  of  them,  have  been  attacked 
by  disease  with  which  their  parents  never  had  been  or  could  be 
affected;  among  other  instances  is  sterility,  noticed  in  all  the 
daughters  born  of  the  same  parents.  Squamous  disease  of  the 
skin  and  scrofula  appear  sometimes  in  all  the  children  born  of  the 
same  parents,  although  they  may  never  have  had  those  diseases. 
We  must  then,  with  Portal,  admit  family  diseases,  which  although 
never  observed  in  father  or  mother,  but  declaring  themselves  in  all 
their  children,  are  evidently  ascribable  to  the  influence  exercised 
in  generation  by  the  concurrence  of  two  determinate  organizations, 
which  give  rise  to  one  differing  from  each  of  the  others,  the 
same  thing  happening  in  all  the  offspring  of  such  connection. 

We  shall  not  give  a  detailed  account  of  the  different  theories 
which  relate  to  the  hereditary  transmission  of  disease.  Like  ex- 
ternal characteristics,  this  transmission  is  a  well  marked  phenom- 
enon, but  quite  as  inexplicable.  The  various  hypotheses  on  this 
subject  may  be  seen  in  the  little  work  of  Meara.  *  The  Consider- 
ations of  Portal  upon  hereditary  and  family  diseases  will  be  read 
with  much  greater  interest  by  those  who  prefer  facts  to  explana- 
tions: in  this  work  the  learned  author  has  collected  all  that  is 
useful  and  curious  upon  this  point  in  pathology,  f 

B.  Age.  This  is  not,  properly  speaking,  a  morbific  cause. 
No  perioid  of  life  plays  an  active  part  in  the  production  of  disease, 
but  there  is  greater  liability  to  certain  affections  at  some  ages  than 
at  others.  Some  complaints  never  appear  previous  to  or  after  a 
certain  period;  on  this  account,  those  aptitudes  for  contracting 
disease  which  belong  to  the  different  ages,  possess  a  peculiar 
interest  for  the  student. 

Many  affections  may  be  developed  at  all  periods  of  our  existence, 
from  intra-uterine  life  to  the  most  advanced  age.  Children  have 
been  born  with  intermittent  fever  and  with  variolic  eruption,  both 
of  which  may  occur  at  any  other  age.  There  are,  however, 
diseases  peculiar  to  every  age,  or  at  any  rate  of  more  frequent 
occurrence  during  such  periods.  Hydrocephalus  and  spina  bifida 
are  developed  while  the  foetus  is  yet  in  utero.  The  diseases 
most  frequently  noticed  at  birth  are  the  asphyxia  of  the  new-born, 

*  Palhologia  hereditaria  generalis,  sive  de  morbis  hereditariis  tractatus,  spa- 
gyricodogmaticus. —  (Authore,  Derm.  Meara;  Dublin.  1619.) 

f  Considerations  sur  la  Nature  et  le  Traitement  des  Maladies  de  Famille  et  des 
Maladies  hereditaires,  par  Antoine  Portal.  1814.  Paris. 


40  ETIOLOGY. 

icterus  and  hardening  of  the  cellular  tissue.  From  the  first  to 
the  seventh  year,  the  child  is  chiefly  exposed  to  the  eruptive 
fevers,  to  the  accidents  of  dentition,  epistaxis,  croup,  whooping- 
cough,  tinea,  rachitis,  scrofulous  complaints,  acute  hydrocephalus, 
tubercular  meningitis  and  verminous  affections.  The  period  of 
puberty  in  females  is  fraught  with  various  diseases.  In  both 
sexes,  rapidity  of  growth  sometimes  disposes  the  system  to 
serious  affections.  Plethora,  inflammatory  disease,  haemoptysis, 
angina  and  pulmonary  consumption  are  more  frequent  in  youth 
than  at  any  other  age.  In  middle  life,  hypochondriasis,  haemor- 
rhoids,  cancer  and  the  greater  portion  of  organic  diseases  occur, 
scrofula  excepted.  In  old  age,  softening  and  haemorrhage  of  the 
brain,  idiocy,  deafness,  cataract,  affections  of  the  urinary  passages, 
etc.,  are  more  common  than  in  earlier  life. 

The  etiological  study  of  the  different  ages  offers  still  another 
consideration,  viz.  the  inaptitude  of  certain  ages  for  developing 
certain  diseases.  Thus  cerebral  haemorrhage  is  hardly  ever  ob- 
served before  middle  life;  nor  scirrhus  and  arterial  aneurism 
previous  to  the  thirtieth  year ;  typhoid  fever  has  perhaps  never 
been  observed  after  the  age  of  fifty -five.  These  data  are  occasion- 
ally very  useful  in  diagnosis. 

C.  The  ancients  supposed  there  were  certain  fixed  years  in 
human  life,  when  diseases  were  more  frequently  developed  and 
attended  with  greater  mortality.  They  called  them  climacteric 
years,  from  the  word  *;u>a,  tendency,  or  from  xAi>a$,  signifying  a 
scale  or  degrees.  They  compared  these  years  to  knots,  which 
might  be  said  to  unite  the  different  periods  of  life,  and  to  give  a 
new  direction  to  the  economy.  This  doctrine,  which  is  said  to  have 
been  derived  by  Pythagoras  from  the  Chaldean  institutions,  was  for 
a  long  time  in  great  favor  in  the  schools.  Nearly  all  who  have  ad- 
mitted the  climacteric  years,  have  fixed  them  at  intervals  of  seven 
years ;  they  asserted  the  fourteenth  and  twenty-first  years  to  be 
replete  with  danger.  Others  have  divided  them  into  periods  of  nine 
years.  Some  mingled  the  two,  and  the  sixty-third  year,  composed 
of  the  numbers  seven  and  nine,  was,  in  their  estimation,  the  most 
fruitful  in  diseases,  especially  those  of  fatal  termination.  Others 
preferred  a  triennial  interval.  All  of  them  supposed  that  the  space 
of  time  they  thus  allotted,  was  requisite  for  the  complete  renovation 
of  the  constituent  elements  of  the  body ;  so  that  at  the  end  of  three, 
seven  and  nine  years,  there  did  not  remain  in  the  system  any  of 
those  parts  which  previously  composed  it;  and,  admitting  this 
entire  change  in  the  constitution,  an  analogous  change  in  the 
health  seemed  to  them  the  almost  unavoidable  consequence.  It  is 
very  certain,  that  in  an  indefinite  time,  varying  according  to  age 
and  many  other  circumstances,  the  body  is  renewed,  and  that 
hardly  any  of  its  former  constituent  parts  are  then  found  in  it ; 
but  this  change  is  not  a  sudden  one :  it  is  continuous,  and  modifies 
unceasingly  the  component  parts  of  the  body.  It  is  no  more  per- 
ceptible at  the  seventh  or  ninth  year,  than  upon  every  day  which 


ETIOLOGY.  41 

goes  to  make  up  the  climacteric  periods.  These  useless  specula- 
tions have,  with  great  reason,  been  rejected;  they  seem  fitted 
merely  to  torment  the  imagination  of  the  sick.  * 

D.  The  sexes  are  nearly  alike  in  their  predisposition  to  most 
diseases :    fevers,  inflammations,  nervous  and  organic  affections, 
attack  males  and  females  without  distinction.     If  there  be  any 
difference  between  their  diseases,  it  is  rather  to  be  attributed  to 
the  mode  of  life,  than  to  sex.     If  the  male  be  more  subject  to 
wounds,  contusions,  fractures,  rheumatic  affections  and  typhus,  it 
is  because  he  is  more  exposed  to  the  causes  of  such  affections.     In 
like  manner,  in  cities,  women  are  more  subject  to  nervous  diseases 
than  men.     But  in  the  opposite  case ;  if  we  compare  the  female 
who  labors  in  the  fields,  to  the  man  who  leads  a  luxurious  and 
inactive  life  in  the  city,  the  former  will  be  observed  to  be  liable  to 
the  same  complaints  as  the  man  whose  occupations  are  similar, 
and  the  latter  to  all  those  nervous  affections  which  have  been  con- 
sidered as  peculiar  to  females.    There  are,  indeed,  certain  diseases 
which  attack  one  or  other  of  the  sexes  most  frequently ;  of  these, 
tuberculous  disease  of  the  lungs  is  more  common  in  females  than 
males ;  and  that  this  difference  is  observable  in  every  period  of  life, 
any  one  may  be  convinced  by  consulting  the  statistics  of  M.  M. 
Louis,  Benoiston  de  Chateauneuf  and  Papavoine. 

There  are  certain  diseases  which  almost  exclusively  belong  to 
sex :  not  to  mention  those  of  the  genital  organs  and  their  appen- 
dages, as  hydrocele  and  sarcocele  in  man,  scirrhus  and  inflamma- 
tion of  the  uterus  and  ovaries  in  the  female,  stone  in  the  bladder 
and  retention  of  urine  are  almost  exclusively  confined  to  the  male 
sex,  while  crural  hernia,  hysteria  and  mammary  cancer  are  pecu- 
liar to  women. 

E.  Temperament  predisposes  to  various  affections,  and  gives  a 
peculiar  character  to  any  that  may  be  developed.     In  the  san- 
guine temperament,  there  is  a  tendency  to  plethora,  to  deep-seated 
inflammation,  haemorrhages,  etc. ;  and  almost  all  the   acute  dis- 
eases occurring    in  persons   thus  constituted,    are   accompanied 
with  general  symptoms  of  inflammatory  fever.     The  bilious  tem- 
perament is  conducive   of   bilious   diarrhoea,    the  exanthemata, 
inflammations  of  the  membranes  and  organic  disease,  especially 
cancerous  degeneration.     Those  of  a  lymphatic  temperament  are 
peculiarly  liable  to  catarrh,  chronic  discharges,  dropsy,  scrofula, 
and  scurvy ;  and  nearly  all  the  acute  diseases  which  affect  them  are 
of  an  adynamic  character,  and  slow  in  their  progress.     Those  of  a 
nervous  temperament  are  particularly  subject  to  hysteria,  hypochon- 

*  Some  authors  have  given  a  different  signification  to  the  word  climacteric : 
they  understand  by  it  the  periods  of  life  at  which  great  changes  occur,  indepen- 
dently of  the  numerical  order  of  the  years  ;  such  is  the  epoch  of  puberty  in  both 
sexes  and  the  suspension  of  the  menstrual  discharge,  or  critical  season,  in  females. 
Every  one  allows  the  influence  of  these  climacteric  epochs  upon  the  constitution 
and  health. 

4* 


42  ETIOLOGY. 

driasis,  convulsions,  disturbance  of  the  sensations  and  intellectual 
faculties,  melancholy,  mania,  etc. ;  and  in  addition  to  the  ordinary 
symptoms  of  acute  disease,  various  disorders  of  innervation,  which 
alter  the  character  of  the  affection,  make  its  course  irregular  and 
its  termination  less  certain.  The  mixed  temperaments  predispose, 
though  less  energetically,  to  the  affections  peculiar  to  each  of  the 
temperaments  united  in  the  same  individual. 

F.  A   very   strong  constitution   seems   rather   a  preservative 
against  all  disease  than  a  predisposant  to  any.     Nevertheless,  it 
has  been  observed  that  such  constitutions  are  more  subject  than 
others  to  acute  and  violent  inflammatory  affections.     Those  of 
feeble  constitution,  on  the  contrary,  are  liable  to  frequent  and  slight 
attacks  of  disease,  and  to  habitual  indisposition,  and  nearly  all  of 
them  die  of  chronic  disease.     It  has  also  been  remarked,  but  with- 
out sufficiently  accurate  data,    that  very  corpulent  persons  are 
subject  to  apoplexy,  and  are  almost  entirely  exempt  from  inflam- 
mations of  the  thoracic  organs.  * 

The  disposition  of  each  part  of  the  body  seems  also  to  have  an 
influence  in  hastening  the  development  of  disease.  Considerable 
volume  of  the  head  should  lead  us  to  apprehend  hydrocephalus  in 
children  and  apoplexy  in  the  aged.  A  remarkably  broad  chest 
excites  suspicion  that  the  contained  organs  have  a  size  dispropor- 
tioned  to  that  of  the  other  viscera,  and  this  disposition  is  like  the 
first  stage  of  cardiac  aneurism.  Those  in  whom  all  the  cavities 
are  large,  or  to  use  the  expression  of  Hippocrates,  who  have  volumi- 
nous viscera,  are,  according  to  this  prince  of  medicine,  liable  to 
arthritis.  The  weakness  of  the  aponeuroses  which  correspond  to 
the  natural  apertures  of  the  abdomen,  is  the  chief  predisposing 
cause  of  hernia.  The  structure  of  the  bones  in  children,  favors 
the  detachment  of  their  epiphyses  and  their  abnormal  curvature  ; 
in  the  adult,  the  angles  which  the  neck  of  the  femur  forms  with 
its  supporting  bone,  and  the  ramus  of  the  lower  jaw  with  its 
body,  favor  the  fracture  of  the  one  and  the  dislocation  of  the 
other.  Finally,  in  the  aged  subject,  the  diminished  thickness  of 
the  compact  part  of  the  bones,  the  predominance  of  their  inorganic 
element,  and  the  increased  size  of  the  medullary  cavity  of  the 
long  bones,  are  each  circumstances  explanatory  of  the  frequency 
of  fracture  in  old  age. 

G.  Habits,  which  arise  from  the  frequent  repetition  of  the  same 
acts  in  a  given  time,  are  usually  injurious  to  those  who  become 
enslaved  by  them,  and  they  are  very  properly  numbered  among 

*  Obesa  corpora  minus  pleuritidi  el  peripneumonia,  sunt  obnoxia,  ut  animad- 
vertit  aequb  diligens  ac  eruditus  medicus  Trillerus.  Quod  cum  omnes  peripneu- 
monicos  a  me  visos  aut  curatos  memoria  repeto,  verum  esse  intelligo  ;  et  ipse 
poteris,  perlectis  eorum  qui  a  Valsalva  itemque  a  me  dissecti  fuerunt  historiis 
cunctis,  duobus  exceptis,  facile  cognoscere.  (MORGAGNI  de  Sed.  et  Caus.  morb., 
Epist.  XX.  art.  10.) 


ETIOLOGY.  43 

the  predisposing  causes  of  disease.  The  power  of  habit  and  the 
danger  of  its  discontinuance  are  in  proportion  to  its  duration  and 
the  number  of  actions  committed  under  its  influence  in  a  given 
time.  So  great  is  this  power  that,  as  Cabanis  has  remarked,  it 
would  be  dangerous  to  change  from  the  worst  regimen  to  the 
wisest  and  best.  Now  as  there  is  no  habit  which  we  can  be  sure 
of  satisfying  through  life,  it  is  prudent  not  be  bound  by  any,  unless 
absolutely  compelled.  Many  habits  are  injurious  to  the  health 
from  the  moment  they  are  contracted;  all  may  become  so  if 
interrupted. 

H.  The  professions  may  predispose  to  different  diseases,  by  the 
concurrence  of  circumstances  in  which  those  practising  them  are 
placed.  Literary  men  are  subject  to  headaches,  wakefulness,  and 
haemorrhoids ;  many  die  of  apoplexy.  Faggot-bearers  are  subject 
to  hernia ;  watermen,  to  a  peculiar  alteration  of  the  dermis,  charac- 
terized by  softening,  fissures,  and  frequently  absorption  of  the  parts 
in  contact  with  the  water;  *  while,  contrary  to  the  common  opin- 
ion, they  are  rarely  affected  with  ulcers  of  the  legs ;  f  varicocele 
is  of  frequent  occurrence  in  horsemen. 

I.  Statistics  collected  by  numerous  distinguished  physicians, 
demonstrate  satisfactorily  the  sad  influence  of  poverty  upon  mor- 
tality. Dr.  Villerme  has  proved  by  very  interesting  researches, 
that  in  Paris  and  many  other  large  cities,  the  proportion  of  deaths 
to  the  number  of  inhabitants  in  the  different  quarters,  is  in  an 
inverse  ratio  to  their  degree  of  comfort.  J  M.  Benoiston  of  Cha- 
teauneuf  has  arrived  at  similar  conclusions ;  he  has  observed  that, 
at  the  same  periods  of  life,  the  mortality  among  the  poor  is  almost 
double  that  of  the  rich.  ||  The  diseases  most  usually  observed 
under  these  circumstances  among  the  poor  are  scurvy,  scrofula, 
tinea  and  some  other  exanthematous  diseases;  in  the  higher 
classes,  inflammatory  and  nervous  diseases  are  most  frequent. 

It  nevertheless  sometimes  happens  that  similar  affections,  not 
contagious,  such  as  catarrh  and  erysipelas,  prevail  simultaneously 
in  both  classes. 

J.  The  state  of  health,  of  convalescence  or  of  disease,  has  like- 
wise an  influence  upon  the  facility  of  development  of  various 
affections. 

It  would  be  absurd  to  rank  health  among  the  preparatory  causes 
of  disease.  There  are,  however,  certain  affections  which  are 
observed  only  in  those  who  previously  enjoyed  perfect  health; 
such  is  the  ephemeral  fever  produced  by  an  evident  external  cause ; 

*  This  affection,  peculiar  to  the  skin,  has  received  the  name,  grenouilles.  See 
the  Memoir  of  Parent-Duchatelet  upon  porters  employed  to  unload  boats.  — An- 
nales  de  hyg.  publ.  t.  iii.  p.  245. 

f  Of  670  boat  porters  examined  by  Parent-Duchatelet,  one  only  had  an  ulcer. 

\Annal.  d'hyg.  et  de  med  leg.  t.  iii.  p.  294. 

||  Annal.  d'hyg.  et  de  mid.  Mg.  t.  iii.  p.  5. 


44  ETIOLOGY. 

the  same  cause  would  have  excited  in  another  person  a  more 
serious  malady,  etc.  Descriptions  of  epidemics  also  exist,  in  which 
the  prevailing  disease  attacked  healthy  individuals  by  preference, 
as  it  were,  while  feeble  and  infirm  persons  escaped.  But  the 
opposite  of  this  has  been  almost  constantly  observed,  and  a  dis- 
eased condition  must  always  be  considered  as  favorable  to  the 
development  of  prevailing  complaints,  and  as  a  predisposing  cause 
of  various  affections.  Diemerbroeck  states,  that  in  the  plague  of 
Nimegue,  all  those  who  were  attacked  by  any  complaint  whatever, 
were  soon  afterwards  affected  with  the  contagious  malady ;  the 
same  was  remarked  in  the  epidemic  cholera  of  Paris  in  1832,  and 
has  been  noticed  in  many  other  epidemics.  Oedema  of  the  glottis 
scarcely  ever  occurs  except  among  patients  already  seriously  ill. 
Convalescence  is  accompanied  by  a  debility  and  susceptibility, 
which  greatly  accelerate  the  action  of  morbific  causes. 

K.  Pregnancy,  likewise,  renders  the  system  liable  to  different 
diseases.  Many  women  experience  some  nervous  affection  during 
gestation,  as  vomiting,  depraved  appetite,  cramp  and  convulsive 
movements;  or  plethoric  accidents,  as  headache,  ringing  of  the 
ears,  oppression,  or  palpitations,  which  yield  to  venesection,  etc. ; 
during  the  period  immediately  succeeding  delivery,  the  suscepti- 
bility of  women  to  attacks  of  acute  disease,  to  which  the  epithet 
puerperal  is  given,  is  singularly  augmented ;  every  one  knows 
how  frequent  these  affections  are ;  the  uterus  with  its  appendages 
is  most  usually  the  origin  of  disease;  acute  metritis  supervenes 
more  often  under  these  circumstances,  than  in  any  others.  The 
same  is  true  in  inflammation  of  the  mammae  during  lactation. 
Nursing  women,  and  those  who  have  lately  weaned  their  children, 
are  very  easily  affected  by  the  action  of  the  productive  causes  of 
rheumatism :  they  often  experience  its  attacks,  and  it  then  receives 
the  popular  name  of  milk  pains. 

2.  INDIVIDUAL  PREDISPOSING  CAUSES,  PROPERLY  so  CALLED. 

Having  pointed  out  the  various  conditions  which  we  have 
styled  aptitudes,  and  which  may  predispose  to  disease,  we  shall 
briefly  examine  the  individual  predisposing  causes,  properly  so 
called,  which  belong  to  the  second  series. 

A.  General  causes  prevail  in  the  class  of  the  circumfusa  ;  still 
there  are  some  that  act  upon  isolated  individuals,  as  the  fre- 
quenting of  dissection  rooms  and  hospitals,  which  disposes  to  dis- 
ease of  an  adynamic  character  ;  also  an  habitual  residence  in  con- 
fined, ill-aired,  and  overheated  apartments,  which  renders  the 
body  more  sensible  to  external  cold,  and  more  likely  to  be  affected 
by  it. 

Change  of  climate,  which  is  a  general  predisposing  cause  for 
troops  transported  to  the  colonies,  is  more  frequently  an  individual 


ETIOLOGY.  45 

predisposing  cause.  The  inhabitants  of  the  country  when  they 
come  to  reside  in  cities,  almost  always  experience  some  disorder  ; 
within  the  first  few  days,  diarrhoea,  or  severe  fever  after  some 
months'  residence.  The  greater  number  of  those  who  retire  to  the 
country,  after  having  spent  the  first  part  of  their  lives  in  cities, 
as  for  instance,  merchants  who  have  become  independent,  or  pub- 
lic functionaries  who  have  lost  their  situations  through  political 
vicissitudes,  soon  experience  more  or  less  disturbance  of  health, 
which  often  results  in  death.  But  we  should  observe,  that,  in  all 
such  cases,  many  other  alterations  assist  the  mere  change  of  dwell- 
ing-place in  causing  the  result  thus  observed. 

B.  Some  individual  predisposing  causes  are  found  among  the 
applicata.  Clothing,  when  too  thin,  favors  the  action  of  causes 
productive  of  catarrh  and  rheumatism.  That  which  is  too 
warm,  determines  indirectly  a  similar  effect  by  increasing  the 
susceptibility.  The  form  of  the  dress,  which  changes  according 
to  the  fashion  and  tastes  of  the  various  classes  of  society,  is  not 
without  its  influence  upon  the  health.  Many  physicians  think 
that  the  costume  adopted  since  the  French  Revolution,  has  con- 
tributed very  much  to  render  pulmonary  consumption  more  com- 
mon among  females,  and  croup  among  children ;  the  exposure  of 
the  neck,  the  arms,  and  the  upper  part  of  the  chest,  accounts 
apparently  for  the  frequency  of  these  diseases.  It  has  been  said 
also,  that  the  Greeks  and  Romans,  whose  legs  were  habitually 
bare,  were  more  subject  than  we  are,  to  erysipelas  of  those  parts. 

Among  the  morbific  agents  belonging  to  the  applicata,  those 
acting  through  the  medium  of  winpression  probably  produce  the 
most  remarkable  effects. 

The  immediate  effect  of  all  compression  is  to  diminish  the  vol- 
ume of  the  parts  subjected  to  it,  and  almost  constantly  to  inter- 
fere with  the  action  of  the  organs,  to  retard  the  circulation  of 
the  fluids,  and  particularly  of  the  venous,  and  even  the  arterial 
blood.  In  this  case,  compression  may  have  a  rapid  and  manifest 
effect,  like  the  specific  causes ;  the  gangrene  which  occurs  in  a 
tumor,  whose  base  is  surrounded  by  a  ligature,  and  asphyxia 
caused  by  compression  upon  the  trachea,  are  examples ;  but  in  the 
great  proportion  of  cases,  the  effects  of  compression  manifest 
themselves  slowly,  like  those  resulting  from  the  action  of  predis- 
posing causes. 

These  effects,  which  are  exceedingly  various,  might  belong  to 
either  predisposing  or  determining  causes ;  still  we  have  included 
them  under  one  head,  so  as  not  to  separate  them  from  those  phe- 
nomena which  are  more  interesting  when  studied  collectively; 
they  depend  on  the  nature  of  the  compressing  agents,  the  struc- 
ture of  the  parts  compressed,  the  time  during  which  the  compres- 
sion is  continued,  the  extent  of  surface  compressed,  and  the 
force  with  which  it  is  applied. 

I.  The  agents  capable  of  producing  compression  are  very  nu- 
merous :  some  are  applied  to  the  surface  of  the  body,  as  the  cloth- 


46  ETIOLOGY. 

ing,  particularly  corsets,  garters,  and  girdles;  others,  whose 
action  is  internal,  are  either  foreign  bodies  or  morbid  growths,  as 
tumors,  effused  liquids,  or  gases,  which  become  an  actual  cause  of 
various  secondary  disorders  by  means  of  the  compression  they 
maintain  upon  the  neighboring  organs. 

The  elastic  corsets  used  by  most  females,  are,  probably,  one  of  the 
causes  which  lead  to  the  development  of  organic  disease  of  the 
lungs  and  heart,  particularly  during  the  period  of  growth  and 
that  of  pregnancy,  when  the  chest  should  rather  be  increased  in 
volume.  In  this  latter  case,  there  are  many  other  inconveniences  : 
the  pressure  upon  the  abdomen  prevents  the  development  of  the 
uterus,  tends  to  give  it  an  abnormal  position,  and  may  excite 
abortion.  Their  action  upon  the  mammae  is  not  less  marked  :  it 
prevents  their  attaining  the  increased  volume  which  they  should 
acquire,  flattens  the  nipple,  and  renders  nursing  difficult  or  im- 
possible. The  stomach  and  intestines  thus  compressed,  some- 
times assume  a  faulty  position,  the  exercise  of  their  functions 
is  always  impaired;  the  inconvenient  and  noisy  borborygmi,  so 
frequent  in  females,  are  probably  owing  to  the  compression  of  the 
intestines  by  corsets ;  this  is  scarcely  ever  observed  in  men. 

Compression,  however  slight,  if  long  continued,  caused  by  sur- 
gical apparatus,  or  by  a  simple  bandage  intended  to  support  the 
dressing  of  an  issue,  may  sensibly  diminish  the  volume  of  the 
part  compressed,  and  sometimes  may  occasion  oedema  of  that  por- 
tion of  the  limb  in  which  the  venous  circulation  is  obstructed. 
Garters,  when  very  tightly  drawn,  may  cause  varicose  dilatation 
of  the  veins.  Very  narrow  socks  worn  in  childhood,  change  the 
conformation  of  the  toes,  and  at  any  age  produce  a  thickening  of 
the  skin  and  the  development  of  those  hard  and  painful  tumors 
called  corns  ;  but  friction  contributes  to  this  result.  The  synovial 
cyst  called  hygroma,  which  is  formed  in  the  neighborhood  of  the 
knee  and  elbow,  in  workmen  whose  employment  forces  them  to 
press  continually  upon  these  parts,  either  with  the  instrument  they 
use  or  against  the  table  at  which  they  work,  is  an  analogous  for- 
mation. Compression  of  the  neck,  by  a  tight  cravat,  excites 
or  increases  the  distension  of  the  cerebral  vessels,  and  favors 
haemorrhage  and  inflammations  of  the  brain. 

Internal  compression,  caused  by  a  tumor,  affects  the  organs  in 
various  ways.  It  attracts  but  little  notice  when  the  tumor  is  be- 
neath the  skin  or  between  the  muscles,  because  the  resistance  is 
slight  and  the  compression  consequently  less.  The  case  is  nearly 
the  same  when  the  tumor  occupies  the  superficial  portion  of  the 
abdomen,  whose  anterior  parietes  are  susceptible  of  considerable 
extension.  But  it  is  otherwise  within  the  skull,  the  thorax,  the 
nasal  fossae,  and  even  the  inferior  parietes  of  the  mouth. 

The  primary  effect  of  tumors  developed  within  the  skull  is  to 
compress  the  corresponding  cerebral  hemisphere,  and  to  induce 
more  or  less  complete  paralysis  of  the  muscles  of  the  opposite 
side.  If  the  tumor  be  near  the  bony  arch  of  the  skull  it  often  hap- 
pens that  it  gradually  reduces  the  thickness  of  the  bone,  even  to 


ETIOLOGY.  47 

the  tenuity  of  parchment,  and  in  some  cases  completely  perforates 
it,  making  its  appearance  through  the  aperture ;  fungous  tumors 
of  the  dura  mater  often  present  this  series  of  phenomena.  Analo- 
gous effects  occur  in  the  chest :  such  as  functional  disturbance, 
and  absorption  of  the  parietes.  If  the  tumor  be  in  the  vicinity  of 
one  of  the  axillary  regions,  it  sometimes  causes,  by  compression 
of  the  arfery,  a  progressive  decrease  in  the  force  of  the  pulse 
upon  that  side,  and  by  compression  of  the  veins  and  lymphatics, 
oedema  of  the  corresponding  limb. 

If  the  compressing  agent  be  a  fluid,  its  effect  is  only  distension 
of  the  natural  or  adventitious  cavity  which  encloses  it,  and  inter- 
ference with  the  action  of  neighboring  organs,  as  is  uniformly 
noticed  in  the  abdomen,  often  in  the  thorax,  and  occasionally  in  the 
skull,  where  ossification  is  incomplete ;  but  absorption  of  the 
bony  walls  never  occurs,  as  it  does  from  solid  tumors. 

2.  The  structure  of  compressed  parts  has  great  influence  upon 
the  phenomena  of  compression.     This  may  be  easily  appreciated 
in  the  chest,  where  the  organs  differ  very  much  from  each  other 
in  texture,  and  whose  parietes  are  composed  of  both  hard  and 
soft  parts.     It  is  observed  that  the  softer  and  more  flexible  the 
tissues,  the  less  change  occurs  in  their  texture,  in  consequence 
of  the  tumors  which  compress  them  ;  on  the  other  hand,  the  harder 
they  are,  the  greater  effect  is  produced.     Thus  an  aneurismal  tu- 
mor of  the  arch  of  the  aorta  causes  absorption  of  the  sternum, 
cartilages  of  the  ribs  in  front,  and  of  the  vertebras  behind,  while, 
for  a  long  time,  it  simply  displaces  the  heart,  and  diminishes  the 
volume  of  the  lungs. 

If  the  trachea  be  compressed,  the  cartilaginous  rings  are  first  de- 
stroyed ;  their  uniting  membrane  resists  for  a  long  time,  as  do  the 
intercostal  muscles  when  the  ribs  and  their  cartilages  are  already 
absorbed.  In  the  case  where  the  tumor  opens  into  the  bronchial 
tubes,  the  oesophagus,  pleurae  or  pericardium,  and  causes  death, 
the  comparative  examination  of  the  different  parts  shows  that 
the  lesion  of  those  which  are  hard  and  resistant  is  greater  and  of 
earlier  date  than  that  of  the  soft  parts.  We  should  notice  that  there 
is  here  something  special  in  the  nature  of  the  compression,  on  ac- 
count of  the  pulsation  occurring  in  aneurismal  tumors ;  both  per- 
cussion and  compression  exist.  The  application  of  this  principle 
and  the  proof  of  its  truth  is  found  in  the  tumor  known  as  ranula, 
which  causes  absorption  and  deformity  of  the  lower  maxillary 
bone  and  of  the  teeth  therein  inserted,  and  only  occasions  simple 
displacement  of  the  soft  parts.  But  in  all  these  cases  the  latter 
resist  only  by  reason  of  their  elasticity  under  the  force  of  the 
compressing  agent.  If  compression  be  so  applied  as  that  they 
cannot  thus  escape  it,  they  feel  its  effects,  and  indeed  much 
sooner  than  the  firmer  tissues  ;  as  is  observed  by  the  formation  of 
eschars  on  those  portions  of  integument  compressed  between  super- 
ficial and  projecting  bones,  as  the  sacrum,  the  great  trochanters, 
and  the  bed  on  which  the  patient  lies. 

3.  The  effect  of  compression  is  proportionate  in  great  measure  to 


48  ETIOLOGY. 

the  time  during  which  it  is  exercised.  When  short,  even  though 
very  violent,  provided  it  be  not  carried  far  enough  to  cause  altera- 
tion in  the  tissue  of  the  organs,  the  latter  immediately  regain  their 
size  and  the  full  exercise  of  their  functions.  After  longer  com- 
pression, for  some  days,  or  weeks,  for  instance,  the  natural  condi- 
tion is  slowly,  but  maybe  completely  regained.  It  is  far  otherwise 
when  compression  has  been  continued  for  a  considerable  time,  as 
for  years ;  it  then  most  usually  happens  that  the  suffering  organ 
does  not  regain  its  primitive  volume  ;  this  is  particularly  the  case 
with  the  lungs  after  pleuritic  effusions.  There  is,  moreover,  this 
difference  between  compression  of  short  and  long  duration,  that  in 
the  former,  the  diminution  in  volume  seems  alone  owing  to  the 
liquid  contents  being  discharged  and  the  solid  parts  brought  more 
closely  together,  while  in  the  latter  there  is  a  real  decrease  in  the 
solids  themselves,  partial  emaciation  or  atrophy. 

4.  The  extent  of  surface  over  which  compression  is  applied,  also 
modifies  its  effects.  A  very  narrow  bandage  may  penetrate  the 
tissues;  a  broader  one  wpuld  not.  When  compression  is  main- 
tained upon  one  particular  portion  of  a  limb,  the  circulation  be- 
comes arrested  below  the  point  of  application.  This  does  not 
happen  if  the  compression  extend  to  the  extremity  of  the  limb. 
Such  are  the  chief  effects  of  compression  in  the  development  of 
disease  either  primitive  or  secondary,  whatever  be  the  agent  or  the 
recipient  organ. 

Beds  also  deserve  some  attention.  The  habit  of  sleeping  upon 
feathers,  by  increasing  cutaneous  transpiration,  favors  the  forma- 
tion of  urinary  calculi  and  disposes  to  nephritis.  A  hard  bed  does 
not  seem  a  predisposing  cause  of  any  complaint.  Seats,  which 
are  very  soft,  and  particularly  those  furnished  with  feather  cush- 
ions (bergeres),  are  conducive  of  sanguineous  congestion  in  the 
uterine  and  hsemorrhoidal  vessels. 

The  daily  use  of  cold  baths  is  thought  to  predisp'ose  to  inflamma- 
tory disease  by  their  tonic  action  upon  most  of  the  organs.  Warm 
baths,  often  repeated,  produce  an  opposite  effect ;  they  weaken  the 
constitution,  and  predispose  to  chronic  discharges  and  diseases  of 
debility.  Want  of  cleanliness  generally  favors  the  development 
of  all  contagious  and  cutaneous  diseases.  Excess  of  cleanliness, 
combined  with  the  use  of  perfumes  and  the  various  resorts  of  lux- 
ury, seems  to  aid  in  the  production  of  nervous  diseases. 

C.  Ingesta.  Food,  liquids  and  remedies  may  dispose  to  various 
diseases  when  improper  use  is  made  of  them. 

In  health,  the  quantity  of  food  and  liquid  should  vary  according 
to  age,  strength,  occupation,  habits,  etc.  Their  moderate  and 
temporary  increase  or  diminution  does  not  usually  produce  func- 
tional disturbance,  but  beyond  certain  limits  the  health  becomes 
deranged. 

A  decided  and  long  continued  diminution  in  the  ordinary  quan- 
tity of  food  causes  analogous  loss  of  strength  and  flesh  ;  its  increase 
produces  plethora.  Habitual  excess  in  food  seems  to  dispose  to 


ETIOLOGY.  49 

organic  disease  of  the  stomach  and  intestines,  which  is  not 
always  avoided  by  extreme  abstinence.  The  daily  abuse  of  fer- 
mented liquors,  of  wine  or  alcoholic  drinks,  gives  to  acute  diseases 
so  grave  a  character  as  to  render  them  generally  fatal. 

Wine  and  alcoholic  liquors  are  more  pernicious  in  their  effects 
when  drunk  between  meals  than  when  taken  into  the  stomach 
mixed  with  solid  food.  The  disease  known  as  delirium  >tremens 
is  often  owing  to  the  abuse  of  these  drinks,  or  to  their  sudden  ab- 
straction from  the  intemperate.*  According  to  some  physicians, 
sudden  death  and  spontaneous  combustion  are  not  rare  in  persons 
who  use  habitually  a  large  quantity  of  alcohol.  The  immoderate 
use  of  coffee  disposes  to  cerebral  congestion  and  inflammation  of 
the  stomach  ;  tea,  on  the  contrary,  weakens  this  viscus  gradually, 
and  seems  to  predispose  to  chronic  discharges.  Some  authors 
have  attributed  the  frequent  occurrence  of  leucorrhea  in  women  re- 
siding in  cities  to  this  cause,  and  others  have  seen  the  use  of 
beer  produce  blennorrhagia  in  both  sexes.  It  has  been  said  that 
the  use  of  cider  and  beer  in  England  and  Normandy,  is  the  chief 
cause  of  the  rheumatism  so  common  in  those  countries ;  but  is  not 
this  rather  to  be  attributed  to  the  conditions  which  prevent  the  cul- 
tivation of  the  vine,  and  to  the  moisture  of  the  soil  ? 

The  bad  quality  of  food  containing  in  itself  but  little  nutriment, 
or  altered  by  putrefaction,  fermentation  or  mouldiness,  disposes 
to  disease  of  more  or  less  severity,  as  inflammations  of  the  diges- 
tive canal,  adynamic  fevers,  scurvy,  etc.  The  use  of  bad  water,  like 
that  drunk  on  shipboard  during  long  voyages,  of  sour  wine,  or 
badly  prepared  cider,  produces  analogous  effects. 

Variety  in  food  is  necessary  to  man.  The  satiety  experienced 
after  having  for  a  long  time  used  the  same  alimentary  substances 
and  the  satisfaction  experienced  by  a  change,  prove  the  truth  of  this 
assertion.  The  exclusive  use  of  any  one  article  of  food,  in  those 
whose  unrestrained  habits  would  have  been  opposed  to  such  a 
course,  almost  always  terminates  in  disease  ;  farinaceous  food  dis- 
poses to  plethora,  fat  and  oily  articles  induce  chronic  discharges, 
and  animal  substances  give  rise  to  inflammatory  complaints  of 
every  description ;  salted  food,  in  conjunction  with  want  of  vegeta- 
bles and  the  fruits  of  the  season,  produces  scurvy;  the  prolonged 
use  of  a  scanty  regimen  is  a  frequent  cause  of  obstinate  constipa- 
tion and  various  digestive  troubles,  in  those  who  fast  throughout 
Lent. 

Spices  and  powerful  condiments,  as  pepper,  mustard,  pimento,  etc., 
increase,  at  first,  the  energy  of  the  stomach  ;  but  this  viscus  becomes 
accustomed  to  the  action  of  such  excitants,  which  soon  cease  to 
stimulate  it,  and  inactivity  frequently  succeeds  the  temporary  ex- 
citement. The  abuse  of  these  substances  may  cause  inflammation 
of  a  part  or  the  whole  of  the  digestive  canal,  of  the  mouth,  the 
pharynx,  stomach  and  intestines. 

Medicines,  considered  by  most  persons  as  means  of  preserving 

*  BLAKE,  Edinb.  Med.  and  Surg.  Jour.,  t.  xix. 
5 


50  ETIOLOGY. 

and  re-establishing  the  health,  may  sometimes  disturb  it.  Reme- 
dies styled  precautionary,  far  from  strengthening,  often  injure  the 
health.  Repeated  emetics  have  finally  caused  weakness  or  even 
inflammation  of  the  stomach,  and  purgatives  thus  used  have  had 
the  same  effect  on  the  bowels.  The  use  of  medicine  not  indicated 
in  the  course  of  a  disease,  may  instantly  cause  a  new  affection  or 
aggravate  the  existing  complaint. 

D.  Excreta.  The  evacuations  may  vary  considerably  without 
derangement  of  the  health  ;  usually,  one  being  augmented,  another 
is  diminished,  so  that  the  balance  of  the  system  is  preserved. 
Slight  changes  in  the  quantity  of  the  evacuated  matters,  either 
more  or  less,  do  not  suffice  for  the  production  of  disease  ;  but  when 
the  disproportion  between  the  excreted  matter  and  the  reparatory 
means  becomes  very  considerable,  it  acts  upon  the  constitution  and 
so  modifies  it,  as  to  predispose  it  to  various  affections.  If  the  quan- 
tity of  food  daily  assimilated  be  greater  than  the  portion  excreted, 
a  tendency  to  plethora  and  inflammations  of  every  kind  is  the  con- 
sequence ;  if,  on  the  contrary,  absorption  is  not  sufficient  for  the 
reparation  of  the  daily  losses  of  the  economy,  the  body  gradually 
diminishes  and  is  liable  to  complaints  resulting  from  debility. 
Profuse  sweating,  copious  salivation,  too  great  secretion  of  milk  in 
nurses,  etc.,  cause  the  latter  effect.  In  man,  venereal  excess  and 
masturbation  act  in  a  similar  manner,  with  this  peculiarity,  that 
nervous  phenomena  almost  always  accompany  the  debility  arising 
from  repeated  evacuations  of  semen. 

The  debility  induced  by  excessive  evacuations,  brings  into  ac- 
tion the  occasional  and  determining  causes  of  disease.  Thus  a 
man  who,  during  his  whole  life,  has  exposed  himself  with  impu- 
nity to  the  inclemencies  of  weather,  is  attacked  with  rheumatism, 
when  exposed  after  excess  in  venereal  indulgence.*  The  same 
circumstance  disposes  to  attacks  of  yellow  fever  at  St.  Domingo  ;f 
and  Diemerbroeck  J  observed  at  Nimegue,  that  all  who  married 
during  the  continuance  of  the  plague,  were  attacked  by  the  con- 
tagion a  few  days  after  their  nuptials.  Abundant  hemorrhage, 
bleeding,  and  repeated  purgatives,  have  had  the  same  effect  during 
many  other  epidemics. 

Natural  or  artificial  evacuations,  when  reproduced  at  nearly 
equal  intervals,  have  a  very  different  effect,  especially  when  they 
are  confined  within  certain  limits ;  the  system  repairs  and  sup- 
ports these  losses,  either  by  the  diminution  of  other  evacuations, 
or  by  the"  assimilation  of  a  greater  proportion  of  food ;  from  this, 
plethora  results.  Periodical  evacuations,  natural  or  artificial,  cause 
this  to  yield,  but  at  the  same  time  they  increase  the  tendency  to 
its  reproduction,  so  that  nothing  more  strongly  predisposes  to  ple- 
thora, or  at  any  rate,  to  strengthen  the  predisposition  to  it  when 

*  Essai  sur  la  Rhumatisme,  1813. 

f  Traite  de  la  Fievre  jaune,  par  BALLY. 

j  DIEMERBROECK,  de  la  Peste  de  Nimegue. 


ETIOLOGY.  51 

existing,  than  these  evacuations.  The  menstrual  discharge  in 
females,  periodical  haemorrhoids  in  males,  and  habitual  bleeding 
in  both  sexes,  often  produce  this  effect. 

The  suppression  of  habitual  evacuations,  the  omission  of  cus- 
tomary bleeding  and  purging,  may  tend  to  produce  various  com- 
plaints ;  but  they  act  generally  as  occasional,  rather  than  predis- 
posing causes. 

E.  Gesta.  The  precise  degree  of  action  and  rest,  of  sleep  and 
waking,  to  which  man  should  restrict  himself  in  order  to  preserve 
his  health,  cannot  be  determined  ;  nevertheless  there  are  certain 
bounds  which  he  can  rarely  pass  without  deranging  the  harmony 
of  the  functions. 

Any  marked  disproportion  between  exercise  and  repose  always 
injures  the  health  ;  too  great  fatigue  induces  a  kind  of  debility,  and 
gives  an  adynamic  character  to  acute  affections  developed  under 
such  conditions.  It  has  been  said  of  country  people,  that  usually 
they  have  but  one  disease  in  their  lives,  and  that  fatal  to  them . 
Partial  exercise  may  also  predispose  to  certain  affections  ;  the  con- 
tinual and  repeated  movements  of  the  arms,  for  instance,  seem 
calculated,  in  a  greater  degree  than  those  of  the  lower  limbs,  to 
bring  on  haemoptysis  in  those  subject  to  it,  and  to  hasten  the 
progress  of  cardiac  aneurism. 

The  want  of  exercise  is  far  more  replete  with  danger  than  the 
opposite  extreme ;  this  is  more  decidedly  the  case  in  proportion  as 
the  individual  has  need  of  exercise,  on  account  of  his  age,  habits, 
and  strength.  Thus  it  is  most  injurious  to  children,  to  robust  per- 
sons, and  to  those  who  have  always  led  an  active  life.  It  is  ob- 
served that  a  sedentary  life  is  less  prejudicial  to  the  female  than 
to  the  male,  either  because,  from  youth,  habit  has  lessened  in  her 
case  the  troubles  arising  from  it,  or  because  such  a  life  is  more 
conformable  to  her  peculiar  destination,  and  consequently  to  her' 
constitution.  Want  of  exercise  is  the  source  of  many  disorders. 
One  of  its  first  effects,  is  loss  of  appetite  and  slow  digestion ;  dys- 
pepsia frequently  recognizes  this  as  its  sole  cause,  and  yields  only 
to  regular  exercise.  Prolonged  inaction  causes  debility  of  the  lo- 
comotive organs,  favors  sanguineous  congestion  towards  certain 
parts,  and  vitiates  nutrition ;  the  body  increases  in  size  and  loses 
strength ;  adipose  polysarcia,  mucous  discharges,  scrofula,  and 
oedema,  are  the  different  results  of  this  inaction  when  carried  to  a 
great  extent,  the  effects  varying  according  to  the  constitution  of  the 
individual.  The  same  cause,  in  a  less  degree,  exercise  not  being 
quite  sufficient,  disposes  to  plethora,  especially  in  high  livers.  In- 
action of  a  single  limb  usually  produces  mere  local  effects,  such  as 
weakness,  diminution  of  size,  and  atrophy  of  the  part  which  is  kept 
motionless. 

That  change,  which  is  necessary  in  all  the  acts  of  life,  is  espe- 
cially so  in  regard  to  the  positions  of  the  body.  The  restraint 
arising  from  too  long  retention  of  one  position,  the  need  of  chang- 
ing it  at  intervals,  even  during  sleep,  had  already  established  the 


52  ETIOLOGY.  ( 

truth  of  the  above  assertion,  even  prior  to  its  adoption  as  a  hygi- 
enic precept.  The  upright  posture,  when  habitual,  disposes  to 
varicose  affections,  oedema  of  the  legs  in  both  sexes,  varicocele  in 
man  and  prolapsus  uteri  in  women  ;  the  sitting  posture,  to  haemor- 
rhoids and  engorgement  of  the  abdominal  viscera;  the  kneeling  pos- 
ture induces  lumbago  and  early  curvature  of  the  spine  ;  horizontal 
.posture  favors  cerebral  congestion,  epistaxis  and  apoplexy.  This 
latter  position,  when  maintained  for  many  months,  on  account  of 
fractures  of  the  lower  limbs,  has  often  seemed  to  be  the  main 
cause  of  calculous  formations  in  patients  who  had  never  previ- 
ously been  so  affected. 

A  proper  division  of  our  sleeping  and  waking  hours  is  useful 
in  maintaining  health.  From  six  to  eight  hours'  sleep  are  neces- 
sary for  adults  ;  less  is  requisite  for  old  persons,  and  more  for  chil- 
dren. But  here,  as  elsewhere,  general  rules  admit  of  exceptions ; 
some  persons  need  nine  or  ten  hours'  sleep;  four  or  five  are  suf- 
ficient for  others.  Prolonged  sleep  induces  general  sluggishness, 
and  predisposes  to  plethora  and  cerebral  affections.  Those  who 
retire  and  rise  very  late,  who  sleep  in  the  daytime  and  remain 
awake  at  night,  hardly  ever  attain  to  an  advanced  age.  After 
long  watchings,  nervous  affections  are  frequently  developed,  and 
particularly  great  irritability  of  the  nervous  system. 

F.  Percepta.  The  sensations,  passions,  and  intellectual  efforts, 
when  they  exceed  certain  limits,  become  predisposing  causes  of 
disease. 

Sensations,  habitually  very  feeble,  augment  by  degrees  the  sen- 
sibility of  the  organs  which  are  their  seat,  to  such  extent  that  they 
become  unfit  to  bear  those  which  are  moderately  powerful :  this 
is  observed  in  individuals  who  remain  for  a  long  time  in  a  dark 
abode,  and  among  those  who  live  upon  very  unstimulating  food. 
Sensations  habitually  very  lively,  on  the  contrary,  exhaust  the 
sensibility  of  the  organs,  and  render  them  unfit  to  fulfil  their  func- 
tions. 

The  passions  have  a  very  remarkable  influence  upon  the  de- 
velopment of  disease.  While  the  mild  and  varied,  favor  the  har- 
mony of  the  functions,  the  strong  and  exclusive,  are  injurious  in 
the  same  degree.  They  not  only  may  affect  the  system  in  a  sud- 
den and  marked  manner,  as  in  the  instances  of  derangement, 
instant  death  and  hectic  fever  from  moral  causes,  as  we  have  seen 
in  the  enumeration  of  determining  causes ;  but  they  also,  and  far 
more  frequently,  give  rise  to  an  exaggerated  sensibility  which 
peculiarly  predisposes  to  nervous  affections.  Prolonged  grief  seems 
to  have  a  powerful  influence  in  developing  organic  diseases,  es- 
pecially cancer. 

Mental  labor,  when  excessive,  predisposes  to  nervous  affections ; 
but  it  does  not  hence  follow,  as  has  been  supposed,  that  study  is 
contrary  to  nature.  It  is  a  law  of  nature,  that  the  greatest  pos- 
sible intellectual  and  physical  development  should  be  simultane- 
ously attained.  The  exercise  of  the  mind,  meditation  and  study, 


ETIOLOGY  53 

are  necessary  to  the  development  of  the  intellect,  as  motion  is  to 
that  of  the  body.  When  the  object  of  study  suits  the  taste  of  the 
student,  when  it  alternates  with  some  manual  occupation  or  with 
suitable  exercise,  it  rather  benefits  than  injures  the  health.  Many 
literary  men,  physicians  and  mathematicians,  have  attained  to 
very  advanced  age ;  and  if  there  have  been  those  who  have  died 
from  excessive  application,  the  number  is  very  small.  When, 
however,  studies  are  continued  daily  for  many  hours,  and  relate 
to  subjects  in  themselves  uninteresting  and  irksome  to  the  one 
employed  in  them,  when  they  are  not  varied  and  interrupted  from 
time  to  time  by  exercise,  the  body  is  injured  in  its  development ; 
the  energy  of  the  mental  powers  may  be  blunted,  and  in  early 
youth  the  germ  of  the  most  brilliant  faculties  blighted. 

Antecedent  diseases  may  be  added  to  these  different  individual 
predisposing  causes ;  they  strongly  favor  the  action  of  those  spe- 
cific or  occasional  causes  which  are  likely  to  excite  anew  the 
above  named  diseases.  A  first  attack  of  hysteria  or  rheumatism 
not  only  indicates  the  aptitude  of  the  patient  to  be  thus  affected, 
but  seems  to  increase  the  tendency  to  repeated  attacks.  It  has 
often  been  noticed  in  ulterior  attacks  of  hysteria  and  rheumatism, 
that  very  slight  occasional  causes  sufficed  for  the  development  of 
these  affections,  while  the  first  attack  required  the  influence  of 
very  powerful  agency. 


ARTICLE  THIRD. 
Occasional  or  exciting  Causes. 

OCCASIONAL  causes,  as  we  have  stated,  are  those  which  excite 
disease  without  determining  its  nature  or  situation,  and  which  act 
only  with  the  concurrence  of  the  predisposition. 

These  have  not  the  importance  which  attaches  to  those  of  the 
first  two  orders  ;  but  because  they  do  not  belong  to  the  particular 
history  of  any  one  disease,  they  are,  more  than  the  others,  within 
the  domain  of  general  pathology :  their  enumeration  is  therefore 
necessary. 

The  impression  made  by  very  cold  or  very  hot  air,  by  the 
north  or  south  wind ;  the  action  of  a  current  of  air  upon  the 
whole  body,  or  of  a  smaller  draught  (vent  coulis)  upon  one  part  in 
particular  ;  the  sudden  passing  from  a  very  warm  to  a  very  cold 
apartment,  and  vice  versa  ;  a  short  stay  in  a  damp  house,  newly 
built ;  a  temporary  change  in  the  thickness  or  form  of  the  gar- 
ments ;  immersion  in  a  very  hot  or  very  cold  bath,  exposure  to 
rain ;  wet  clothes  retained  upon  the  body ;  errors  in  diet,  as  the 
excessive  ingestion  of  food,  otherwise  of  good  quality ;  the  use 
of  inferior  or  badly  prepared  food,  difficult  of  digestion,  taken 
at  an  unaccustomed  hour  or  hastily  eaten ;  very  hot  or  very  cold 
drinks,  or  those  injurious  by  their  quality;  the  suppression  of 


54  ETIOLOGY. 

certain  natural  evacuations,  as  the  perspiration,  lochia,  milk, 
and  menstrual  discharge ;  or  of  a  morbid  or  artificial  discharge, 
as  that  of  leucorrhea,  chronic  ulcers,  long  established  setons  or 
blisters;  an  habitual  hsemorrhagic  discharge  which  has  become 
necessary  ;  a  natural  evacuation  considerably  increased  ;  untimely 
venesection  ;  emetics  and  purgatives  administered  without  indica- 
tion ;  excessive  fatigue  ;  an  unusual  amount  of  rest ;  cries ;  singing ; 
shouts  of  laughter ;  running  against  the  wind ;  prolonged  watch- 
ing ;  physical  or  moral  shocks ;  lively  emotion,  as  joy  or  terror ; 
necessary  mental  strife ;  retrocession  of  gout ;  disappearance  of 
exanthematous  affections ;  sudden  cessation  of  some  other  com- 
plaint; such  are  the  chief  occasional  causes  of  disease. 

These  differ  from  special  and  predisposing  causes  by  not  being 
connected  with  the  history  of  any  affection  in  particular.  One 
occasional  cause  may  excite  any  disease,  and  the  same  disease 
may  be  induced  by  every  kind  of  occasional  cause.  If  there 
were  any  doubt  as  to  the  correctness  of  this  proposition,  the  ex- 
amination of  any  treatise  on  pathology  would  suffice  for  its  re- 
moval ;  in  the  portion  devoted  to  the  etiology  of  each  disease,  the 
acute  in  particular,  all  the  occasional  causes  we  have  just  named 
would  be  almost  literally  enumerated.  It  is  quite  otherwise  with 
the  determining  causes ;  they  differ  either  in  themselves  or  as  re- 
gards the  parts  upon  which  their  action  is  exerted  in  each  kind  of 
disease.  Notwithstanding  this  great  difference  between  them, 
there  are  many  points  of  contact,  where  the  occasional,  are,  as  it 
were,  mingled  with  the  determining  and  predisposing  causes.  For 
instance,  is  cold  a  determining  or  an  occasional  cause  of  rheuma- 
tism ?  The  different  opinions  of  physicians  prove  that  this  is  a 
point  not  easily  decided.  On  the  other  hand,  if  we  compare 
occasional  and  predisposing  causes,  it  will  be  seen  that  the  same 
circumstances  may  belong  to  each.  There  is,  it  is  true,  this  differ- 
ence, that  in  the  one  case,  the  cause  is  momentary  in  its  action, 
while  in  the  other,  that  action  has  been  of  long  duration;  an  error 
in  diet  is  an  occasional  cause ;  habitual  intemperance,  on  the 
contrary,  is  predisposing ;  the  distinction  is  very  marked  when 
our  examples  are  extreme  cases,  but  becomes  more  obscure  in 
proportion  as  they  are  less  so ;  excesses  which  are  prolonged  for 
many  days,  for  one  or  several  weeks,  can  hardly  be  said  to  belong 
decidedly  to  either  class.  There  are  some  circumstances  where  a 
simple  error  in  diet,  usually  considered  one  of  the  occasional 
causes  of  disease,  becomes  a  predisposing  cause.  During  epidemic 
variola  or  prevailing  plague,  excessive  drinking  or  venereal  indul- 
gence often  repeated  in  the  space  of  a  few  hours,  have  frequently 
been  observed  to  favor  the  action  of  the  pestilential  or  variolic 
virus,  and  the  individual  who  for  months  had  braved  contagion 
with  impunity,  has  been  attacked  immediately  after  being  debili- 
tated by  these  causes,  which,  in  these  cases,  evidently  acted  as 
predisposants. 

This  division  of  morbific  causes  presents  some  defects ;  nature 
does  not  submit  herself  to  our  divisions  in  this  instance  any  more 


ETIOLOGY.  55 

than  in  others ;  she  cannot  be  rigorously  bound  by  any.  The 
proposed  arrangement  seems  more  methodical  and  practical  than 
others ;  above  alt,  it  is  particularly  suitable  as  our  guide  in  the 
study  of  morbific  causes,  considered  in  regard  to  their  mode  of 
action. 


ARTICLE    FOURTH. 
Mode  of  Action  of  Morbific  Causes. 

ALL  the  organs  of  the  human  body  are  not  equally  exposed  to 
the  action  of  morbific  causes ;  the  alimentary  canal,  the  lungs  and 
the  skin  are  more  apt  to  receive  from  them  an  injurious  impres- 
sion on  acccount  of  their  more  intimate  relations  with  external 
objects.  Huf eland  in  his  Pathogeny*  has  for  this  reason  denomi- 
nated them  atria  morborum,  the  gates  of  disease.  To  them  should 
be  added  the  brain  and  nerves,  which  especially  in  civilized  man, 
are  directly  exposed  to  the  action  of  a  large  class  of  morbific 
causes. 

Among  the  agents  which  disturb  the  health,  there  are  those 
which,  impelled  by  a  greater  or  less  force  communicated  to  them, 
or  by  means  of  their  chemical  qualities,  penetrate  into  the  substance 
of  the  organs ;  their  action  is  purely  physical  or  chemical ;  their 
effects  would  be  the  same  upon  the  dead  body.  Among  these  are 
bodies  which  cause  wounds,  caustic  substances  and  fire.  Others 
influence  only  the  living  tissues,  and  can  act  only  by  the  power  of 
vital  laws.  Such  are  acrid  plants  and  rubefacients.  whose  action 
is  confined  to  the  skin  and  mucous  membranes  with  which  they 
are  in  immediate  contact ;  food  and  drink,  and  perhaps  poisons, 
and  certain  miasmata  which  penetrate  the  system  through  the  ab- 
sorbent vessels,  and  whose  morbific  effects  may  be  felt  very  far 
from  the  spot  where  they  were  first  deposited  ;  the  passions,  sensa- 
tions and  intellectual  efforts  which  manifest  themselves  through 
the  nervous  system,  are  also  of  the  same  class. 

We  shall  not  extend  farther  our  remarks  upon  the  mode  of  ad- 
mission of  these  causes  into  the  system ;  but  will  proceed  to  point 
out  the  modus  operandi  of  the  three  classes  of  causes  which  we 
have  proposed. 

§  I.  The  action  of  specific  causes  is  usually  evident,  although 
not  always  easy,  and  often  impossible  to  explain. 

When  a  wounding  instrument  penetrates  any  part,  fractures  a 
bone,  injures  a  tendon  or  an  artery,  we  suppose  the  force  which 
divided  these  organs  to  have  been  superior  to  that  which  preserved 
their  continuity ;  we  can  likewise  account  for  the  disordered  mo- 
tions, and  the  flow  of  blood  which  result  from  such  injuries.  A 
foreign  body  in  the  trachea  or  bladder  causes  symptoms  easy  of 

,  disease  ;  ytroi/at,  to  exist. 


56  ETIOLOGY. 

explanation,  because  its  action  is  wholly  mechanical.  The  case  is 
similar  when  the  passage  of  alimentary  matter  is  intercepted, 
where  the  intestines  are  compressed  by  a  tumor,  or  strangulated 
by  a  peritoneal,  or  hernial  stricture.  We  can  understand  likewise 
how  a  violent  contraction  of  the  muscles  may  cause  hernia,  dislo- 
cation, fracture  of  the  patella,  or  rupture  of  a  tendon  ;  but  most  of 
the  causes  we  have  enumerated,  while  they  exert  a  mechanical 
action  upon  living  organs,  produce  other  effects  subordinate  to  the 
vital  laws.  Thus,  divided  or  displaced  parts  become  red,  hot, 
painful  and  swollen ;  a  new  secretion  is  established  in  them,  etc. 
There  is  nothing  surprising  to  us  in  these  phenomena,  because  we 
are  accustomed  to  observe  them.  But  if  we  desire  to  examine 
them  thoroughly  and  to  know  the  mechanism  of  their  production, 
we  are  compelled  to  acknowledge  our  ignorance,  unless  we  are 
willing  to  substitute  error  in  its  place,  or  veil  it  by  language  which 
imposes  even  upon  ourselves.  Notwithstanding  the  progress  of 
modern  chemistry,  we  are  constrained  to  say  the  same  thing  in  re- 
gard to  the  action  of  the  gases  which  produce  asphyxia.  We 
know  that  some  suspend  gradually,  and  others  immediately  the 
phenomena  of  life;  we  are  acquainted  also  with  the  changes 
caused  by  some  of  these  agents  in  the  color  and  consistence  of  the 
blood ;  but  asphyxia  still  remains  unexplained.  The  action  of  the 
poisons  upon  the  economy  is  equally  well  demonstrated,  but  quite 
as  inexplicable.  Why  is  a  species  of  coma  caused  by  the  narcotic 
poisons  ;  inflammation  of  the  stomach  and  intestines  by  the  acrid, 
and  gangrene  of  various  parts  by  the  septic  1  These  are  questions 
which  do  not  admit  of  reply.  We  can  more  easily  understand  the 
effects  of  fire  and  caustics,  because  they  are  partially  the  same 
upon  all  organized  bodies;  but  their  peculiar  action  is  quite  as 
much  beyond  our  penetration. 

The  action  of  contagious  principles  is  yet  more  obscure.  To  a 
certain  extent  we  are  acquainted  with  the  agents  of  which  we  have 
just  spoken ;  we  appreciate  the  physical  and  chemical  properties 
of  the  irrespirable  and  the  deleterious  gases,  caustics  and  some  poi- 
sons. This  is  not  the  case  with  contagious  principles,  for  they 
escape  our  senses,  and  those  whose  action  is  most  easily  appreciated, 
as  vaccine  and  variolic  virus,  cannot  be  separated  from  the  vehicle 
which  contains  them,  and  studied  in  regard  to  their  properties. 
Thus  it  is  only  by  a  process  of  reasoning  that  we  admit  their  ex- 
istence. 

Many  authors  have  compared  the  development  of  contagious 
diseases  to  that  of  vegetables,  and  likened  the  contagious  principles 
to  their  seeds.  If  we  bear  in  mind  what  has  previously  been  said 
of  contagion,  it  will  be  easy  to  see  the  principal  points  of  analogy 
between  them;  but  the  resemblance  is  far  from  complete.  The 
existence  of  plants  and  the  seeds  from  which  they  spring,  is  mani- 
fest and  does  not  admit  of  doubt.  The  existence  of  contagious 
principles,  on  the  contrary,  is  only  admitted  as  a  consequence  of  a 
series  of  facts  which  are  thus  clearly  explained,  and  which  other- 
wise would  remain  inexplicable.  Certain  diseases  being  capable 


ETIOLOGY.  57 

of  transmission  from  affected  to  healthy  individuals,  this  mode  of 
transmission  has  been  called  contagion,  and  the  inappreciable 
agent  is  called  a  contagious  principle. 

The  action  of  contagious  principles  is  obscure  for  many  other 
reasons.  Do  they  act  directly  upon  the  nerves  of  the  part  with 
which  they  are  brought  in  contact,  or  are  they  absorbed  into  the 
rest  of  the  system  ?  These  two  opinions  have  been  supported  by 
quite  plausible  arguments  ;  and  each  might  be  true  as  regards  cer- 
tain poisons,  for  it  is  possible  that  all  may  not  obey  the  same  laws 
in  their  manner  of  entering  the  system. 

The  efficacy  of  cauterization  practised  fifteen  or  twenty  days 
after  the  bite  of  a  rabid  animal,  has  led  some  practitioners  to  the 
conclusion  that  the  poison  of  rabies  is  not  absorbed,  and  that  being 
simply  deposited  in  the  soft  parts  which  received  the  wound,  its 
action  is  at  first  confined  to  the  nervous  extremities  which  there 
exist,  from  whence,  in  time,  it  extends  to  the  rest  of  the  nervous 
system.  But  in  other  contagions  diseases,  the  pain,  swelling, 
and  redness  which  occur  in  the  track  of  the  lymphatic  vessels  and 
glands,  seem  to  prove  the  absorption  of  certain  poisons,  although 
some  authors  have  attributed  these  phenomena  to  sympathy. 
Admitting  absorption,  what  is  the  absorbing  surface,  if  these  poi- 
sons are  volatile  ?  Is  it  the  skin,  or  the  mucous  membrane  of  the  air 
passages,  into  which  they  are  carried  with  the  air  ?  or  that  of  the 
alimentary  canal  where  they  enter  mingled  with  the  food  or  sali- 
va? Some  authors  have  supposed  that  contagious  principles 
cannot  act  upon  the  membrane  of  the  stomach,  because  all  the 
substances  introduced  into  this  viscus  are  there  digested  and  conse- 
quently become  changed.  This  is  an  ingenious  supposition  ;  but 
if  we  remember  that  variola  has  been  inoculated  by  mingling  some 
of  the  dried  scabs  with  the  food  and  drink,  it  will  be  allowed  that 
this  supposed  decomposition  of  the  virus  by  the  action  of  the 
stomach  or  by  the  gastric  juice  is  still  very  doubtful.  Others  have 
asserted  that  contagious  principles  could  be  absorbed  by  those  or- 
gans only  in  which  their  symptoms  appeared ;  that  variola  and 
scarlatina  were  contracted  by  the  skin,  syphilis  by  the  mucous 
membranes,  etc. ;  but  in  the  existing  state  of  our  knowledge,  it  is 
more  reasonable  to  admit  that  nearly  all  the  contagious  agents  may 
be  absorbed  by  every  surface  with  which  they  come  in  contact  ; 
and  that  being  once  introduced  into  the  economy  they  act  specially 
upon  those  organs  which  seem  most  congenial  to  each  of  them. 

After  having  studied  the  action  of  the  evident  causes  of  disease, 
we  shall  examine  in  like  manner  the  predisposing  causes,  com- 
mencing with  aptitudes. 

$  II.  Aptitudes. 

The  age,  sex,  temperament,  constitution,  the  degree  of  comfort, 
the  healthy  or  diseased  condition,  and  pregnancy,  seem  neither 
actively  to  concur  in,  nor  to  oppose,  the  production  of  disease. 
Their  influence  is  appreciated  with  difficulty,  but  their  action 


58  ETIOLOGY. 

cannot  be  doubted  when  general  conclusions  are  drawn  from  a 
large  number  of  facts.  If,  for  instance,  we  collect  all  the  obser- 
vations which  relate  to  any  particular  affection,  and  observe  that, 
in  every  case,  or  at  least  in  the  greatest  number,  the  disease 
declares  itself  at  a  certain  age,  and  in  persons  of  certain  tempera- 
ment, we  must  admit  that  these  circumstances  constitute  favorable, 
perhaps  necessary  conditions  for  the  development  of  such  disease. 
Thus,  croup  is  incontestably  more  frequent  during  infancy  than  at 
other  periods  of  life,  phthisis  in  youth,  arterial  aneurism  and 
cancer  in  adult  years,  haemorrhage  and  softening  of  the  brain  in 
old  age.  Females  are  more  disposed  to  hysterical  affections; 
males,  to  hypochondriasis ;  some  epimedics  prevail  among  the 
poor,  others  among  the  opulent,  etc.  In  fact,  the  influence  of 
aptitudes  grows  more  obscure,  as  we  descend  from  general  conclu- 
sions to  individual  applications  ;  for  instance,  it  does  not  absolutely 
follow  because  scrofula  affects  children  more  frequently  than 
adults,  and  shows  a  preference  for  the  lymphatic  temperament, 
that  these  two  conditions  have  always  concurred  in  its  production, 
when  observed  in  such  circumstances  ;  but  this  does  not  invalidate 
the  fact  that,  generally,  this  age  and  temperament  favor  the  affec- 
tion. It  is  no  reason  because  typhoid  fever  occurs  chiefly  in 
youth,  rarely  in  the  adult,  and  never  after  the  age  of  fifty-five, 
that  the  season  of  youth  has  an  active  agency  in  its  production, 
but  it  shows  that  the  liability  to  contract  it,  is  bounded  by  certain 
limits  in  regard  to  age,  beyond  which  it  does  not  pass. 

The  influence  of  age  in  the  development  of  disease,  is  far  more 
evident,  than  that  of  either  temperament,  constitution,  sex,  or 
degree  of  comfort.  There  is  no  disease  incompatible  with  any 
temperament  or  constitution,  or  with  either  sex ;  while  certain  ages 
are  exempt  from  some  affections,  and  others  are  peculiarly  exposed 
to  them. 

It  is  universally  conceded,  that  of  all  the  conditions  comprised 
under  the  name  of  aptitudes,  hereditary  transmission  has  the 
greatest  influence  in  producing  disease.  In  some  affections,  in- 
deed, it  is  an  active  predisposing  cause,  rather  than  a  mere 
aptitude.  Children  of  phthisical  origin  are  in  imminent  peril  of 
this  fearful  disease,  by  reason  of  that  origin  alone;  and  the  larger 
proportion  of  them  are  attacked  by  it,  however  they  may  be  cir- 
cumstanced. The  influence  of  birth  is  less  powerful  in  some  other 
diseases,  as  rheumatism,  stone,  apoplexy.  Children  of  parents 
thus  afflicted  are,  other  things  being  equal,  more  liable  to  be 
affected;  but  other  causes  must  often  concur  in  order  to  their 
production,  and  even  then  they  are  not  all  attacked. 

$  III.  Predisposing  Causes,  properly  so  called. 

Although  usually  obscure,  the  action  of  predisposing  causes  can 
often  be  explained  in  a  satisfactory  manner.  It  is  easy  to  conceive 
how  certain  diseases,  as  indigestion  and  abortion,  may  be  caused 
by  too  tight  clothing  or  corsets.  The  disposition  to  plethora, 


ETIOLOGY.  59 

when  it  follows  the  use  of  very  nutritious  food,  and  anaemia,  which 
is  the  effect  of  abstinence  and  poor  diet,  may  be  easily  accounted 
for.  The  debilitating  influence  of  excessive  evacuations  of  every 
sort,  and  the  tendency  to  inflammation  which  results  from  the 
suppression  of  habitual  evacuations,  is  quite  as  clearly  explained. 
So  it  is  with  regard  to  the  effect  of  habitual  repose  or  excessive 
fatigue  upon  the  health.  Nervous  disease  in  anxious  or  melan- 
choly persons,  or  in  those  who  devote  themselves  exclusively  to 
mental  labor,  is  naturally  connected  with  the  causes  productive  of 
these  affections.  The  influence  of  the  air  and  the  dwelling  is 
commonly  more  obscure,  although  plausible  explanations  have 
been  given  in  regard  to  it. 

Predisposing  causes  must  not  be  confounded  with  predisposi- 
tions ;  the  latter  depend,  but  not  constantly,  upon  the  former.  All 
persons  are  not  uniformly  affected  by  the  same  predisposing  causes, 
and  a  predisposition  to  disease  cannot  be  accurately  determined 
by  the  apparent  power  of  the  causes  which  produced  it.  In  one 
case,  a  slight  predisposing  cause  will  establish  a  very  decided 
predisposition;  in  another,  a  number  of  such  causes,  of  greater 
power  and  longer  continued  action,  will  have  far  less  effect,  or 
perhaps  none  whatever.  In  many  instances  we  are  compelled  to 
acknowledge  a  decided  predisposition  to  certain  diseases  in  those 
who  have  not  been  exposed  to  any  of  their  developing  causes. 

Whenever  a  disease  appears  without  apparent  cause,  a  frequent 
occurrence  in  internal  pathology,  we  must  have  recourse  to  a 
latent  predisposition  to  explain  its  production  ;  and  this  doubtless 
consists  in  a  peculiar  modification  (whose  essence  is  wholly  un- 
known) either  of  the  whole  system,  or  of  one  or  many  of  its 
constituent  parts.  Thus  in  pneumonia,  erysipelas,  or  articular 
rheumatism,  it  is  in  almost  every  case  impossible  to  point  out, 
from  a  consideration  of  the  antecedent  circumstances,  the  causes 
which  have  produced  either  of  these  affections.  Great  obscurity 
also  surrounds  the  origin  of  organic  diseases. 

Observation  shows  us  that,  in  some  persons,  one  organ  is  much 
more  frequently  affected  than  the  rest,  or  is  even  the  exclusive 
seat  of  almost  all  the  diseases  which  manifest  themselves  during 
an  entire  life,  or  at  any  rate,  during  one  or  more  of  its  great  divis- 
ions, as  infancy,  youth,  or  adult  age  :  in  one  individual  the  lungs, 
in  another,  the  stomach  or  intestines,  in  a  third  the  brain,  are,  in 
popular  terms  the  feeble  organs,  that  is,  the  most  liable  to  the 
action  of  morbific  causes.  The  advocates  of  the  theory  of  irrita- 
tion proposed  to  call  this  tendency  of  an  organ  to  become  diseased 
diathesis,  *  and  they  admit  pulmonary,  gastric,  cerebral  and 
uterine  varieties ;  but  with  most  authors  and  in  the  usual  language 
of  science,  this  word  has  a  different  acceptation.  Diathesis  is  a 
disposition  through  whose  influence  many  portions  of  thfe  body, 
either  simultaneously  or  in  succession,  become  the  seats  of  spon- 
taneously developed  affections,  identical  in  their  nature,  although 

,  disposition. 


60  ETIOLOGY. 

variable  in  external  appearance.  Consequently,  as  many  sorts  of 
diathesis  must  be  admitted,  as  there  are  diseases  which  show 
themselves  in  various  organs  simultaneously  or  otherwise,  by  the 
agency  of  a  common  internal  cause  :  this  latter  condition  is  barely 
admissible.  If  various  forms  of  inflammation,  as  peritonitis, 
pneumonia  and  ophthalmia,  should  occur  simultaneously  in  the 
same  patient,  each  arising  from  evident  external  causes,  there  is  no 
existent  diathesis;  but  if  these  affections  are  developed  without 
distinct  cause,  they  are  then  attributed  to  a  common  predisposition, 
styled  inflammatory  diathesis.  —  Rheumatic,  gouty,  tuberculous, 
cancerous,  gangrenous,  herpetic,  scorbutic,  osseous  and  aneurismal 
diatheses,  have  been  admitted ;  to  these,  the  varicose,  melanic, 
ulcerative  and  hsemorrhagic  should  be  added. 

The  simultaneous  development  in  many  parts  of  the  system,  of 
rheumatic  or  gouty  affections,  of  tubercle,  cancer,  gangrenous 
disease,  herpetic  eruptions,  scorbutic  symptoms,  osseous  and 
aneurismal  tumors,  varix,  melanotic  deposits,  ulcers,  granulations 
and  haemorrhage  declares  the  existence  of  the  corresponding 
diatheses.  We  admit  also  a  granular  diathesis  which  most  physi- 
cians regard  as  a  variety  of  the  tubercular.  Some  authors  mention 
a  dropsical  diathesis,  which  is  incorrect,  since  dropsy  is  in  general 
merely  a  symptom.  The  mucous  and  bilious  diatheses  are  too  ill 
defined  for  retention  among  scientific  terms.  Finally,  we  do  not 
allow  the  purulent  diathesis  of  some  writers,  because  it  is  most 
frequently  a  mere  infection ;  nor  a  syphilitic  or  variolous  diathesis, 
because  these  diseases  do  not  recognise  an  internal  cause,  but  are 
owing  to  the  evident  absorption  of  a  virus  whose  mode  of  action 
is  wholly  unlike  that  of  diathesis. 

A  peculiar  disposition  exists  in  a  few  instances,  which,  either  in 
the  exercise  of  some  function,  or  in  the  impression  made  upon  it 
by  external  agents,  produces  phenomena  wholly  different  from 
those  which  are  observed  in  most  persons  in  similar  circumstances ; 
such  are  the  syncope  caused  by  the  sight  of  certain  objects,  or  by  a 
kneeling  posture  maintained  for  some  time ;  and  the  urticaria  noticed 
in  some  individuals  whenever  they  take  certain  food,  as  strawberries 
and  shellfish.  There  are  persons  upon  whom  exposure  to  the  exter- 
nal air  has  uniformly  the  same  effect  during  the  cold  season.  Bour- 
dier  saw  at  the  Hotel  Dieu  of  Paris,  a  man  forty  years  of  age, 
become  affected  with  intermittent  fever  whenever  elastic  bougies 
were  introduced  into  the  urethra.*  An  exceptional  predisposition 
must  universally  be  admitted,  through  whose  agency,  in  certain 
persons,  like  causes  always  produce  remarkable  effects.  This  is 
called  morbific  idiosyncrasy. 

Predisposing  and  individual  causes  may  act  in  unison  or  singly. 
Their  energy  is  in  proportion  to  their  mutual  action,  or  tendency 
to  modify  the  economy  in  a  similar  manner. 

Among  a  large  population,  the  individual  rarely  agree  with  the 
general  predispositions,  from  which  it  results  that  all  the  inhabi- 

*  Theses  de  la  Faculte  de  Medecine  de  Paris,  annte  1809,  No.  17. 


ETIOLOGY.  bl 

tants  of  a  district  are  very  seldom  simultaneously  attacked  by 
disease,  except  it  spring  from  a  contagious  principle,  that  is,  a  spe- 
cific cause  acting  independently  of  predisposing  causes.  An  affec- 
tion uniformly  developed  by  the  latter,  hardly  ever  attacks  more 
than  one  third  or  one  quarter  of  a  population ;  most  usually 
only  one  tenth,  one  twentieth,  or  even  a  less  proportion.  We 
can  sometimes  be  certain,  that  those  attacked  by  the  prevailing 
malady,  are  those  in  whom  the  influence  of  general  predisposing 
causes  has  rendered  more  active  that  of  the  individual  pre- 
disposing causes.  When,  for  instance,  bilious  affections  are  very 
common,  persons  of  bilious  temperament,  who  live  chiefly  on 
animal  food,  etc.,  are  more  often  attacked,  while  the  sanguine  or 
lymphatic,  being  less  impressible  by  general  predisposing  causes, 
possess  a  resisting  power  in  their  very  constitution.  Thus,  other 
things  being  equal,  the  latter  are  more  rarely  and  less  severely 
affected,  while  the  former  are  more  generally  attacked  and  with 
more  violence  and  rapidity.  There  are,  however,  many  excep- 
tions to  this  rule. 

t.  Individual  predisposing  causes  are  sufficient  of  themselves  to 
produce  most  diseases.  There  is  no  affection  which  may  not  be 
occasionally  developed  in  isolated  individuals,  independently  of 
general  predisposing  causes.  Angina  and  pneumonia,  for  instance, 
although  more  frequent  in  certain  seasons,  may  occur  in  all,  through 
the  influence  of  individual  predisposing  causes  only.  Often,  while 
certain  diseases  prevail  under  the  influence  of  general  causes,  indi- 
vidual predisposing  causes  develope  affections  of  a  wholly  different 
nature.  It  is  in  this  way  that  inflammatory  diseases  may  appear 
in  certain  persons  inhabiting  places  where  dropsy  and  scurvy  *e 
endemic. 

2.  On  the  other  hand,  general  predisposing  causes,  when  exceed- 
ingly active,  may  exert  an  influence  independently  of  the  individ- 
ual predisposants,  and  even  notwithstanding  the  resistance  they 
offer.  Thus  it  is  that  diseases  developed  during  public  calamities, 
as  famines,  sieges,  etc.,  fall  upon  all  classes  of  society,  almost 
without  distinction ;  neither  is  any  temperament  or  age  exempted, 
as  has  been  observed  in  many  epidemics,  particularly  at  Modena* 
and  Naples,  f 

As  regards  their  relative  energy,  then,  we  find  that  general  pre- 
disposing causes  may  neutralize  the  effect  of  individual  causes, 
and  bring  on  diseases  entirely  in  opposition  to  the  latter,  and  vice 
versa. 

Before  concluding  what  we  have  to  say  of  predisposing  causes, 
we  remark,  that  if  there  be  certain  conditions  which  dispose  to 
disease,  there  are  likewise  many  which  are  preservative  of  health. 
Without  mentioning  in  this  connection  that  unknown  power  called 
vital  force,  which,  as  has  been  said,  appears  to  struggle  incessantly 
against  the  destructive  agents  which  surround  us,  there  are  condi- 

*  RAMAZZINI,  1690-93. 
f  SARCONE,  1764. 


62  ETIOLOGY. 

tions  which  exempt  us  from  certain  affections ;  habit,  in  particular, 
is  one  of  these.  By  it  the  most  indigestible  articles  of  food  are  par- 
tially deprived  of  their  injurious  effects,  and  the  pernicious  energies 
of  the  most  subtle  poisons  destroyed ;  the  Turks  use  opium  with 
impunity,  and  Mithridates,  according  to  historians,  became  insen- 
sible to  poisons.  We  must  not  suppose,  however,  that  the  daily 
use  of  deleterious  substances  has  no  injurious  effect  upon  the  econ- 
omy ;  habit  does  not  wholly  free  us  from  their  action ;  it  merely 
alters  and  strikingly  enfeebles  it. 

The  power  of  certain  contagious  principles  seems  to  be  exhaust- 
ted  in  like  manner  by  the  force  of  habit.  In  places  where  yellow 
fever  is  endemic,  the  inhabitants  are  not  attacked  by  it,  as  at 
Havana  and  Vera  Cruz,  for  instance.  The  Turks  resident  at  Con- 
stantinople seem  to  be  as  much  habituated  to  the  principle  of  the 
plague,  which  is  in  almost  continual  action  in  some  parts  of  the  city, 
as  they  are  to  opium  by  daily  use.  We  may  with  as  much  propriety 
conclude  that  if  the  visiting  physicians  of  hospitals  are  not  more 
frequently  than  others  the  victims  of  typhus  when  widely  epidemic, 
it  is  because  they  have  become  accustomed  to  the  action  of  the 
contagious  principle  before  it  has  acquired  its  full  power. 

The  force  of  habit  goes  yet  farther,  and  deprives  even  chemical 
agents  of  a  portion  of  their  influence  over  living  tissues.  There 
are  those  who  handle  with  impunity  bodies  at  a  very  high  temper- 
ature, as  burning  coals,  or  iron  bars  whose  opposite  extremity  is 
incandescent ;  others  have  accustomed  themselves  to  swallow  boil- 
ing liquids  without  any  sensible  inconvenience.  Tartra  relates  the 
curious  fact,  that  a  woman  given  to  intemperance,  had  passed 
fifcm  the  immoderate  use  of  wine  to  that  of  brandy,  then  of  alco- 
hol, and  even  of  ether  ;  at  last,  unaffected  by  these  liquids,  she  fin- 
ished by  drinking  nitric  acid,  without  experiencing  from  it  any 
remarkable  injury.* 

It  is  hardly  necessary  to  add,  that  age,  sex  and  temperament  are 
all  conditions  which  should  be  considered  preservative  against  cer- 
tain affections.  Primitive  scirrhus  or  aneurism  are  never  observed 
in  infancy ;  one  instance  only  of  croup  is  recorded  in  old  age. 

We  have  already  seen  that  some  contagious  diseases  attack  the 
same  person  but  once  during  life ;  those  who  have  been  affected, 
are  consequently  exempt.  A  very  extraordinary,  although  very 
well  known  phenomenon,  is  the  reciprocally  preservative  property 
of  variola  as  regards  vaccinia,  and  vice  versa.  This  fact  which 
is  unique  in  the  history  of  contagious  disease,  naturally  leads  us  to 
suspect  a  similarity  of  origin  in  these  affections. 

Finally,  there  exists  a  fortunate  disposition,  whose  nature  is  un- 
known, but  whose  effects  are  appreciable,  which  protects  from  cer- 
tain maladies.  There  are  some  individuals  who  appear  to  be 
insusceptible  of  the  contagion  of  variola,  or  vaccinia.  Others  ex- 
pose themselves  daily  to  syphilis  with  impunity.  In  all  the 
instances  of  epidemic  typhus  or  yellow  fever  there  are  some  who 

*  Empoison,  par  V  acide  nilr.,  p.  124. 


ETIOLOGY.  63 

brave  the  contagion  and  escape  the  disease.  When  the  plague 
was  at  Marseilles,  the  venerable  Belzunce,  patriarch  of  the  city, 
was  not  affected  by  it,  although  almost  constantly  among  the  sick, 
aiding  them  in  every  manner.  In  the  black  plague  which  deso- 
lated the  south  of  France,  in  1347,  another  fact,  no  less  remarka- 
ble, was  noticed ;  of  thirty-five  monks  who  dwelt  in  the  monastery 
of  Mont  Rieux,  one  only  escaped  the  contagion  ;  this  was  Gerard, 
brother  of  the  celebrated  Petrarch,  who  took  care  of  all  the  breth- 
ren and  also  buried  them. 

$  IV.  We  have  considered  the  mode  of  action  exhibited  by  spe- 
cific and  predisposing  causes  in  developing  disease ;  it  remains  for 
us  to  notice  that  of  the  occasional  causes.  The  influence  of  the 
latter  is  not  by  any  means  so  great ;  they  act  only  when  there 
exists  a  predisposition.  Thus,  of  ten  persons  who  may  commit  an 
excess  of  the  table,  or  who  may  be  exposed  to  cold,  etc.,  there 
will  be,  at  farthest,  but  one  or  two  whose  health  will  be  disturbed, 
and  sometimes  out  of  a  larger  number  there  will  be  none  affected. 
Moreover,  these  causes  have  no  influence  upon  the  sort  of  affection 
which  is  developed ;  the  same  occasional  cause  may,  as  we  have 
seen,  excite  any  disease,  and  the  same  disease  may  result  indiffer- 
ently from  any  occasional  cause.  Such  a  cause  is,  as  it  were,  a 
shock  given  to  the  system  ;  it  does  not  affect  those  in  firm  health ; 
in  others  it  may  develope  any  affection  whatever. 

Such  is  the  mode  of  action  of  each  kind  of  morbific  causes. 
There  is  a  certain  number  of  diseases  in  whose  production  some  of 
these  three  classes  of  causes  concur ;  there  are  others  where  the 
disease  arises  exclusively  from  a  specific  cause,  or  from  one  or 
more  predisposing  causes.  Asphyxia  always  depends  on  a  specific 
cause ;  typhus  requires  the  influence  of  some  predisposing  cause  in 
the  majority  of  cases ;  and  sometimes  an  occasional  cause,  as  ter- 
ror, or  too  strict  diet,  may  excite  its  attack  ;  plethora  and  inflam- 
matory fevers  are  almost  always  exclusively  produced  by  predis- 
posing causes ;  no  affection  arises  solely  from  an  occasional  cause. 

The  knowledge  of  causes  is  not  absolutely  necessary  in  particu- 
lar cases.  When  the  disease  is  due  to  specific  causes,  they  are 
easily  appreciated,  but  the  predisposing  causes,  which  are  usually 
obscure,  frequently  escape  the  physician's  sagacity.  The  kind  of 
disease  developed,  may  in  some  cases  lead  to  the  suspicion  of  the 
causes  which  have  produced  it,  and  serve  as  a  guide  in  the  search 
for  them ;  but  in  many  other  instances  these  causes  remain  uncer- 
tain, or  even  unknown.  In  respect  to  occasional  causes,  as  they 
are  immediately  antecedent  to  the  disease,  they  attract  more  par- 
ticularly the  patient's  attention,  which  cannot  fail  to  instruct  the 
physician  ;  but  a  knowledge  of  them  is  generally  of  slight  impor- 
tance, and  many  diseases  make  their  appearance  without  their 
influence. 


64  ETIOLOGY. 

ARTICLE    FIFTH. 
Division  of  Diseases  relatively  to  the  Causes  which  produce  them. 

DISEASES  arising  under  similar  conditions,  or  which  offer  cer- 
tain points  of  resemblance  as  respects  their  causes,  have  been 
grouped  together  and  possess  certain  interesting  relations.  The 
principal  groups  to  which  this  etiological  division  has  given  rise  are 
those  of  innate  and  acquired,  sporadic,  endemic  and  epidemic  dis- 
eases. 

By  innate  or  congenital  diseases  (morbi  cognati,  congeniti)  is 
understood  those  exhibited  by  the  child  at  birth.  They  are  not  all 
hereditary,  neither  do  all  hereditary  diseases  appear  at  the  time  of 
birth.  The  latter  have  existed,  or  are  still  present  in  the  parents, 
and  this  does  not  necessarily  occur  in  regard  to  the  former.  An 
affection  may  be  both  hereditary  and  congenital. 

Under  the  title  acquired  diseases  (morbi  acquisiti,  adventitii) 
are  included  those  not  commencing  till  after  birth  and  independent 
of  hereditary  disposition.  All  diseases  may  come  under  this  head 
except  deformities. 

Sporadic  diseases  (morbi  sporadici*}  are  those  which  attack  a 
single  individual,  or  a  certain  number  of  isolated  persons.  They 
depend  especially  upon  the  predisposing  causes ;  for  the  epithet 
sporadic  is  not  given  to  affections  induced  by  specific  causes.  We 
do  not  say  that  wounds,  fractures,  and  asphyxia  are  sporadic  ; 
this  term  is  applicable  only  to  those  diseases  whose  development 
is  apparently  spontaneous.  Sporadic  diseases  are,  of  all,  the  most 
common ;  they  appear  at  all  seasons,  at  every  age,  and  in  all 
climates,  under  the  action  of  individual  causes. 

Diseases  which  attack  a  mass  of  individuals  at  once,  have  been 
styled  pandemic  (morbi  popular -es);  these  have  been  subdivided 
into  several  series,  according  to  the  circumstances  which  accom- 
pany their  development.  Those  which  appear  every  year  at 
nearly  the  same  time,  are  called  annual  (morbi  annui,  anniversarii)  ; 
those  which  manifest  themselves  uninterruptedly  for  many  seasons, 
or  one  or  more  years,  are  known  as  stationary  (morbi  stationarii)  ; 
those  occurring  at  various  seasons,  and  modified  only  by  prevalent 
affections,  are  termed  intercurrent  (morbi  inter  currentes).  At  the 
present  time  these  names  are  generally  abandoned,  and  two  classes 
only  of  popular  diseases  are  admitted,  endemic  and  epidemic. 

Endemic  f  diseases  (morbi  endemici)  are  those  produced  by  the 
concurrence  of  causes  constantly  or  periodically  in  operation  in 
certain  situations,  so  that  the  diseases  resulting  from  them  are  con- 
stant, or  at  any  rate,  appear  at  fixed  periods,  affecting,  in  every 

*  SniiQta,  to  scatter  here  and  there, 
f  Ev,  in  ;  <*>;/«>£,  the  people. 


ETIOLOGY.  65 

instance,  a  greater  or  less  proportion  of  the  population  ;  such  are 
goitre  and  cretinism  in  the  Valley  of  the  Rhone,  and  intermittent 
fever  in  most  marshy  districts. 

Epidemic*  diseases,  (morbi  epidemici)  which,  like  the  former, 
attack  a  large  number  of  persons  simultaneously,  or  become  far 
more  frequent  than  they  usually  are,  have  a  limited  duration,  and 
do  not  appear  at  regular  intervals.  Their  causes  have  ever  been 
the  object  of  research  to  the  observing  physician.  Nearly  every 
one  is  ready  to  acknowledge  that  most  epidemics  do  not  depend 
solely  upon  the  circumstances  which  surround  the  inhabitants  of 
an  infected  district  ;  and  that  the  action  of  a  succession  of  causes 
for  a  variable  space  of  time,  has  prepared  the  way  for  their  mani- 
festation, and  produced  a  predisposition  which  the  actual  causes 
have  only  developed  or  increased.  It  is  also  observed  in  many 
epidemics,  that  those  who  have  been  resident  for  a  short  time 
only  in  the  region  where  they  prevail,  escape  them,  while  the 
older  inhabitants  are  attacked.  Some  have  sought  for  the  causes 
of  all  epidemics  in  the  food  and  drinks,  but  especially  in  the  sensible 
qualities  of  the  atmosphere.  Others  having  noticed  that  the  changes 
sometimes  occurring  in  the  atmosphere  during  an  epidemic,  do  not 
always  sensibly  influence  its  course,  have  concluded  from  this, 
that  the  exciting  and  continuing  causes  of  prevalent,  diseases  do 
not  exist  in  the  appreciable  qualities  of  the  air.  They  have  thus 
been  led  to  admit  hidden  qualities  in  this  fluid,  to  which  they 
attribute  the  diseases,  whose  occurrence  cannot  be  explained  by 
the  sensible  changes  of  the  atmosphere.  From  this  arises  the  doc- 
trine of  occult  causes,  admitted  under  various  titles,  by  very  cele- 
brated and  highly  judicious  physicians,  from  Hippocrates  to 
Sydenham  and  Mertens. 

Nothing  was  better  suited  to  throw  light  upon  this  question,  than 
the  numerous  epidemic  constitutions,  published  within  two  cen- 
turies. It  was  thought  that  a  constant  relation  would  be  recognised 
between  epidemics  and  the  conditions  under  which  they  manifest 
themselves,  by  means  of  a  careful  comparison,  for  a  series  of  years, 
on  the  one  hand,  of  the  various  states  of  the  atmosphere  and  the  other 
general  morbific  causes  ;  on  the  other,  of  the  diseases  developed 
under  their  influence  :  this  is  the  object  of  epidemic  constitutions. 
The  result,  however,  has  not  answered  the  apparently  well  founded 
expectations  formed  in  regard  to  this  undertaking,  either  because 
the  epidemic  constitutions  were  not  properly  observed  and  de- 
scribed, or  because  epidemics  depend  upon  causes  which  have 
hitherto  escaped  our  means  of  investigation. 

Without  giving  a  decided  opinion  upon  so  obscure  a  question, 
we  shall  remark,  that  among  the  hitherto  described  epidemics, 
there  are  some  which  seem  to  have  fixed  appreciable  causes  :  of 
th  isnumber  are  those  of  Lausanne,  Modena,  Gottingen  and  Genoa  ; 
but  we  must  still  remember  that  a  concurrence  of  causes  resem- 
bling those  already  cited,  would  not  necessarily  produce  like  effects  ; 


*  Enl,  upon  ;  dftiog,  the  people. 
6* 


66  ETIOLOGY. 

and  that  by  far  the  greater  number  of  epidemics  cannot  be  ascribed 
to  any  known  causes,  notAvithstanding  the  great  pains  that  many 
physicians  have  taken  to  indicate  every  circumstance  which  pre- 
ceded or  accompanied  their  development. 

Among  widely  prevalent  diseases,  there  is  a  certain  number 
arising  from  contagion  or  infection,  which  must  not  be  confounded 
with  the  rest,  although  the  majority  of  writers  have  included  them 
under  the  common  denomination,  epidemic  diseases. 

It  is  not  always  easy  to  determine  whether  a  disease  which 
attacks  many  persons  simultaneously,  be  owing  to  general  predis- 
posing causes,  or  to  a  contagious  principle.  It  may  happen  *  that 
a  disease  is  really  contagious  while  it  appears  only  epidemic, 
because  contagion  does  not  affect  all  who  are  exposed  to  its  in- 
fluence, or  because  the  vehicles  of  contagion  and  the  contagious 
principles  being  almost  infinite,  persons  may  be  affected  who 
thought  themselves  removed  from  all  communication  with  the 
sick ;  and  again,  some  other  affection,  considered  contagious,  be- 
cause it  attacks  individuals  who  are  in  communication,  may  be 
dependent  upon  epidemic  influence,  which  is  common  to  all. 
Thus  when  many  persons  occupying  the  same  house,  fall  ill  si- 
multaneously or  successively,  contagion  is  nearly  always  suspected ; 
yet,  as  Ramazzini-\  remarks,  it  is  natural  that  a  number  of  per- 
sons exposed  equally,  and  for  the  same  length  of  time,  to  the 
influence  of  the  same  causes,  should  be  attacked,  at  a  nearly 
identical  period,  with  the  same  disease.  A  sort  of  maturity,  says 
this  distinguished  physician,  supervenes  in  the  system  when 
exposed  for  a  certain  time  to  the  action  of  similar  morbific  causes. 

In  certain  instances,  the  difficulty  of  lulling  all  suspicion  of 
contagion,  hinders  us  from  wholly  denying  its  action ;  and  in  others 
we  cannot  admit  it,  from  not  being  sure  whether  the  disease  is 
ascribable  to  the  state  of  the  atmosphere,  or  to  some  other  general 
cause. 

The  more  volatile  and  easy  of  transmission  the  contagious  prin- 
ciple, the  more  obscurity  surrounds  it. 

Another  circumstance  which  renders  the  distinction  more  difficult 
is,  that  the  majority  of  contagious  diseases  attack  a  population  only 
while  contagion  is  favored  by  a  peculiar  condition  of  the  atmos- 
phere, or  by  other  general  predisposing  causes  to  which  the 
prevailing  malady  might  be  attributed.  Finally,  contagion  some- 
times loses  its  activity  after  a  time,  and  from  observations  at  such 
periods,  we  are  led  to  suppose  that  the  affection  is  not  contagious. 
This  has  been  remarked  in  most  of  the  pestilential  diseases,  par- 
ticularly in  the  typhus  of  Europe,  and  the  plague  of  the  East. 
We  should  find  it  difficult  to  conceive  of  their  gradual  cessation,  if 
this  principle  be  not  admitted. 

There  are,  nevertheless,  certain  circumstances  which  serve  to 
distinguish  contagious  from  epidemic  diseases :  among  these  are 
inoculation  and  importation.  Whenever  a  disease  is  clearly  capable 

*TOMMASINI.    Filvre  jaune.  f  Epidem.  Modlne. 


ETIOLOGY.  67 

of  transmission  from  the  affected  individual  to  the  healthy,  and 
this  transmission  has  been  recognised  in  repeated  instances,  con- 
tagion can  no  longer  be  doubted.  It  is  in  this  manner  that  the 
contagious  nature  of  variola  and  vaccinia  has  been  clearly  proved. 

The  impossibility  of  transmitting  a  disease  by  inoculation,  has 
been  considered  a  negative  means  of  forming  an  opinion  as  to 
contagion.  During  the  prevalence  of  epidemic  cholera,  many 
courageous  and  devoted  physicians  inoculated  themselves  with  the 
matters  excreted  by  the  sick,  with  the  intention  of  throwing  light 
upon  this  question,  whose  solution  was  so  important  to  society. 
While  we  award  to  their  zeal  the  praise  due  to  the  honorable 
motive  which  directed  them,  it  must  be  asserted  that  these  experi- 
ments were  not  sufficient  to  fully  settle  the  question.  All  diseases 
are  not  similarly  contagious ;  many  have  a  peculiar  mode  of  trans- 
mission, out  of  whose  limits  contagion  does  not  manifest  itself. 
Thus  syphilis  is  rarely  contracted  except  by  coitus ;  nor  the 
vaccine  disease,  except  by  the  artificial  insertion  of  the  liquid 
contained  in  the  pustules.  The  same  may  be  true  of  certain  other 
affections ;  and  the  virus  of  Asiatic  cholera,  if  it  exist,  might 
require,  in  order  to  transmission,  a  different  mode  of  inoculation 
from  those  hitherto  tried.  In  addition,  as  we  have  elsewhere 
remarked,  every  individual  is  not  prone  to  receive  the  contagion  ; 
many  more  cases,  also,  are  needed,  in  order  to  solve  the  question, 
and  in  trials  of  this  kind,  negative  have  far  less  influence  than 
positive  results.  Finally,  it  should  be  remarked,  that  the  develop- 
ment of  a  disease  in  those  who  have  been  subjected  to  inoculation, 
cannot  prove  its  contagious  nature,  except  the  inoculation  be  prac- 
tised at  a  distance  from  the  place  where  the  affection  prevails. 
Thus,  whatever  may  have  been  the  results  of  inoculations  which 
took  place  during  the  epidemic  cholera,  and  in  the  regions  where 
it  raged ;  they  were,  from  the  very  first,  of  no  value. 

Importation,  is,  in  this  class  of  cases,  the  most  suitable  means 
of  explaining  these  questions.  When  a  disease  previously  un- 
known in  a  country,  suddenly  makes  its  appearance  there ;  if  its 
manifestation  succeed  the  arrival  of  a  number  of  strangers  who 
may  be  then  affected  with  it,  but  recently  cured,  or  who  come 
from  a  place  where  it  prevails ;  if  those  who  receive  these  strangers 
and  provide  for  them,  are  the  first  to  be  attacked  by  the  disease  ; 
and  if  it  next  appear  among  the  individuals  who  live  with  those 
first  affected,  it  is  evidently  contagious.  It  is  in  this  manner  that 
the  appearance  of  variola  at  the  Cape  of  Good  Hope,  in  the  Faroe 
islands  and  in  many  parts  of  Russia,  where  it  was  previously 
unknown,  would  prove,  if  it  were  necessary,  the  contagious  nature 
of  this  disease.  The  importation  of  scarlatina  into  Podolia,*  as 

*  Hddenbrand  thus  speaks  in  regard  to  this  subject :  "  A  black  coat  which  I 
wore  when  visiting  a  patient  affected  with  scarlet  fever,  and  afterwards  carried 
with  me  from  Vienna  into  Podolia,  without  having  it  on  for  the  space  of  one  year 
and  a  half,  communicated  to  me  this  contagious  disease  upon  my  first  arrival ; 
from  me  it  spread  in  the  province,  where  it  haS  until  then  been  almost  unknown." 
—  (Du  Typhus  Contagieux.) 


68  ETIOLOGY. 

related  by  Hildenbrand,  establishes,  in  like  manner,  its  contagious 
qualities.  Tf  the  importation  of  the  plague,  of  yellow  fever,  or  of 
Asiatic  cholera  were  absolutely  proved,  it  would  leave  no  doubt  as 
to  the  contagious  nature  of  these  diseases.  But  in  the  present 
state  of  Our  knowledge,  these  delicate  questions  are  yet  undecided. 
Many  good  observers  are  convinced  that  these  diseases,  arising  in 
the  first  place  from  miasmata,  are  transmitted  more  particularly 
by  the  accumulation  of  the  sick ;  and  that  consequently  they  are 
infectious.  It  should  be  added,  that  any  disease  arising  from  a 
crowding  of  patients,  and  infectious  in  its  origin,  may  become 
contagious  in  its  future  transmission.  Camp  fever  and  hospital 
gangrene  are  striking  examples. 

Upon  this  subject  we  shall  offer  one  final  remark,  viz.  It  is  not 
in  large  cities  that  the  question  of  contagion  can  be  advantageously 
studied  and  thoroughly  examined.  In  a  place  where  six  or  eight 
hundred  thousand  inhabitants  are  congregated,  unknown  to  each 
other,  it  is  impossible  to  follow  in  its  transmission,  the  most  evi- 
dently contagious  disease.  The  course  of  variola  at  Paris  may  be 
cited  as  an  example,  and  the  impossibility  of  arriving,  in  the  ma- 
jority of  cases,  at  a  knowledge  of  the  period  and  source  of  its  trans- 
mission. On  the  other  hand,  in  places  where  the  inhabitants  are 
fewer  and  better  acquainted,  it  is  usually  easy  to  follow  the 
propagation  of  a  disease ;  all  know  who  were  first  attacked  by  it, 
what  other  persons  have  been  successively  affected,  and  what  com- 
munication they  held  with  those  first  diseased.  On  this  account, 
villages,  and  not  populous  cities,  are  the  places  where  the  mode 
of  propagation  of  diseases  can  be  advantageously  studied,  and 
their  contagious,  infectious,  or  merely  epidemic  character,  most  cor- 
rectly appreciated.  We  do  not,  in  this  connection,  speak  of 
syphilis  or  vaccinia,  which  cannot  be  confounded  with  epidemic 
diseases,  since  they  require  close  contact  in  order  to  their  trans- 
mission.* We  shall  conclude  by  calling  to  mind  this  ancient 
precept,  too  often  combatted  in  our  day,  that  whenever  there  is 
uncertainty  in  regard  to  contagion,  it  is  the  physician's  duty,  as 
also  that  of  the  acting  authorities,  to  proceed  as  if  it  were  proved. 
There  is,  doubtless,  serious  inconvenience  in  declaring  contagion 
to  exist  where  it  does  not  in  reality,  but  there  is  still  greater  in 
mistaking  it  when  really  present,  f 

i 

*  According  to  many  authors,  (and  the  opinion  is  supported  by  certain  histo- 
rical facts,)  it  would  appear  to  be  proved  that  syphilis,  at  the  period  of  its  first 
appearance,  presented  as  ready  a  contagion  as  the  plague  or  variola,  and  that,  in 
course  of  time,  it  became  less  and  less  active.  No  other  contagious  affection 
has  presented  analogous  changes  in  its  mode  of  transmission. 

f  This  motive  would  have  sufficed  to  induce  us  to  rank  yellow  and  typhus 
fever  among  the  contagious  diseases,  even  if  we  had  not  been  convinced,  as  we 
are,  of  their  contagious  nature.  [The  author  ranks  himself  with  the  very  small 
number  of  those  in  favor  of  the  contagious  nature  of  yellow  fever :  the  best 
observers  of  the  present  day  are  decidedly  opposed  to  the  doctrine  of  contagion. 
Grisolle,  in  his  work  on  Internal  Pathology,1  makes  several  assertions  which 

1  Path.  Int.,  Vol.  i,  p.  77,  Deuridme  Edition.    De  La  Fitvre  Jaune. 


ETIOLOGY.  69 

Diseases  have  likewise  been  divided,  in  respect  to  their  causes, 
into  essential,  primitive,  or  protopathic*  and  into  symptomatic, 
secondary,  or  deuteropatkic.\  The  first  are  the  immediate  result 
of  morbific  causes ;  the  second  depend  upon  another  affection,  of 
which  they  are,  properly  speaking,  but  a  symptom.  Haemorrhage 
belongs  occasionally  to  the  latter,  sometimes  to  the  former.  They 
are  essential,  when  not  connected  with  perceptible  lesion  of  the 
organ  where  they  are  seated ;  they  are  symptomatic  in  scorbutus, 
and  many  organic  affections. 

It  is  sometimes  easy  to  determine,  whether  a  disease  is  primitive 
or  secondary :  thus,  when  cancer  of  the  uterus  has  attained  a 
certain  stage,  the  sanious  discharge  cannot  be  mistaken  for  uterine 
catarrh,  and  the  haemorrhage,  which  comes  on  at  intervals,  can- 
not be  considered  as  primitive;  but  it  is  otherwise  when  the 
same  disease  is  only  commencing,  and  the  neck  of  the  uterus 
does  not  yet  present  the  hardness  and  deformity  which  character- 
ize the  disease. 

There  is  a  certain  number  of  affections  which,  however  well 
marked  they  may  be,  are  essential  according  to  some  authors,  and 
are  considered  symptomatic  by  others ;  among  these  are  curva- 
ture and  softening  of  the  bones,  regarded  by  some  physicians  as 
primitive  diseases,  while  others  look  upon  them  as  secondary,  and 
connected  with  scrofula.  The  intestinal  ulcerations  in  typhoid 
fever,  and  the  enlargement  of  the  spleen  in  intermittent  fever,  are 
likewise  of  this  class.  Dropsy  and  the  neuroses  have  been,  and  still 
are,  at  least  in  some  of  their  forms,  subject  to  similar  diversity 
of  opinion.  Exact  observation  and  thorough  discussion  have 
decided  some  of  these  questions,  and  time  will  gradually  lead  to 
the  solution  of  many  others. 


ARTICLE   SIXTH. 

Lapse  of  Time  between  the  Application  of  Causes  and  the  Development 

of  Disease. 

A  CERTAIN  number  of  diseases   are  produced  at   the  moment 
when  the  action  of  their  determining  cause  takes  place ;  this  is 

seem  sufficiently  positive  in  regard  to  the  truth  of  the  opinion  of  the  non-con- 
tagionists ;  he  mentions  the  names  of  Chervin,  Dalmas,  Deveze,  Valentin,  and 
Rush ,  as  among  the  principal  supporters  of  the  latter  doctrine.  The  work  of  Cher- 
vin is  pronounced  by  the  accomplished  editors  of  the  American  edition  of  Marshall 
Hall's  Theory  and  Practice  of  Medicine,  to  be  the  most  elaborate  investigation 
of  the  point  in  dispute  ; '  and  certainly,  if  we  consider  the  time  devoted  to  his 
undertaking,  and  his  unwearied  researches  both  in  Europe  and  America,  his 
opinion  is  entitled  to  our  very  highest  consideration.  Five  hundred  Spanish 
and  American  physicians  out  of  six  hundred,  coincided  with  him  in  favor  of 
non- contagion.  — TRANS.] 

*  IIuQog,  disease;  idiog,  proper;  TT(>WTOC,  first. 

f  jfufiog,  disease  ;  devrtQog,  secondary. 

1  Prin.  of  the  Theor.  and  Practice  of  Med.    By  M.  Hall.    American  Edition,  p.  275. 
Yellow  Fever. 


70  PRECURSORY   PHENOMENA. 

observed  in  contusions,  wounds,  fractures,  and  the  inspiration  of 
certain  deleterious  gases.  The  inflammation  resulting  from  the 
application  of  rubefacients  is  usually  manifested  in  a  short  time, 
as  an  hour,  for  instance ;  the  action  of  vaccine  virus  commences 
at  the  end  of  three  days ;  the  first  symptoms  of  variola  are  not 
evident,  generally  speaking,  till  eight  days  from  the  period  when 
the  contagion  took  place ;  syphilis  is  not  developed  in  some  in- 
stances for  three  or  four  weeks  after  connection,  and  usually  the 
first  symptoms  of  rabies  do  not  declare  themselves  in  adults  be- 
fore  the  thirtieth  or  fortieth  day  after  the  bite. 

The  time  which  elapses  between  the  application  of  contagious 
principles  and  their  first  effects  upon  the  economy,  has  by  many 
authors  been  called  the  period  of  incubation. 

It  is  almost  always  impossible  to  ascertain  accurately  the  time 
since  which  the  predisposing  causes  have  acted :  some  of  these 
causes  are  inherent  in  the  constitution  of  the  individual,  as  age, 
sex,  temperament,  etc.  The  development  of  disease  follows  im- 
mediately, or  at  any  rate,  very  closely,  the  application  of  occa- 
sional causes.  —  M. 


CHAPTER  VI. 


PRECURSORY     PHENOMENA. PRELUDES. ANTECEDENT     SIGNS. PRO- 
DROMES   OR   IMMINENCE    OF   DISEASES. 

ALL  those  phenomena  which  are  exhibited  from  the  moment 
when  the  healthy  action  of  the  functions  begins  to  be  disturbed, 
up  to  the  time  when  the  disease  commences,  are  styled  precursory 
or  antecedent  signs.* 

Diseases  are  not  invariably  ushered  in  by  precursory  phenome- 
na; the  transition  from  perfect  health  to  illness  may  be  sudden. 
Those  affections  which  are  produced  by  specific  causes  never  have 
any  prodrome,  even  when  they  arise  from  contagion.  The  sneezing 
which  precedes  the  eruption  of  rubeola,  the  vomiting  which  occurs 
previously  to  that  of  variola,  cannot  be  considered  as  precursory 
phenomena ;  they  are  the  first  effects  of  the  action  of  the  peculiar 
virus  of  these  two  affections,  and  the  disease  has  already  com- 
menced, although  the  eruption  be  not  apparent.  Preludes  do  not 
take  place,  except  the  affection  be  owing  to  predisposing  causes ; 
none  are  observed  in  chronic  diseases. 

The  precursory  phenomena  have  not,  generally,  any  analogy 
with  the  malady  about  to  be  developed,  and  cannot  lead  us  to  sus- 
pect its  nature.  Those  of  almost  all  diseases  strikingly  resemble 

*  17(36,  before  ;  fyo.uos,  course. 


PRECURSORY   PHENOMENA.  71 

each  other,  and  those  of  the  same  affection  are  scarcely  ever  simi- 
lar. When,  however,  an  epidemic  prevails,  it  may  be  announced 
by  phenomena  which  are  uniform  in  a  large  majority  of  cases,  and 
from  this  the  physician  recognises,  or  at  least  suspects,  the  kind  of 
affection  about  to  appear.  But,  in  most  instances,  the  prodrome 
cannot  lay  the  foundation  of  any  decision,  nor  even  of  reasonable 
conjecture. 

The  precursory  phenomena  of  acute  diseases  are  exceedingly 
varied  and  numerous.  We  shall  mention  those  most  usually  ob- 
served. 

The  attitude  indicates  an  unusual  languor,  the  step  loses  its  or- 
dinary firmness,  there  is  progressive  loss  of  flesh,  the  expression  of 
the  countenance  is  slightly  altered,  in  a  manner  appreciable  only 
by  those  familiar  with  the  individual ;  the  face  is  either  pale,  or 
pale  and  flushed  alternately;  the  least  exercise  causes  fatigue; 
slight  flying  pains,  variable  in  their  seat  and  nature,  are  experien- 
ced in  different  parts  of  the  body,  particularly  the  head  ;  transient 
disturbance  of  the  senses  of  sight  and  hearing  occurs,  as  dimness 
of  vision,  and  tinnitus  aurium ;  the  moral  impressions  are  either 
increased  or  diminished ;  presentiments  of  misfortune  and  inability 
for  mental  exertion,  disturbed  sleep,  its  entire  absence,  or  a  slight 
degree  of  somnolence,  are  frequent  precursory  phenomena  of  dis- 
eases. The  appetite  is  usually  diminished,  rarely  heightened  or  per- 
verted ;  the  mouth  is  often  clammy  or  bitter,  the  thirst  increased,  the 
breath  fetid,  digestion  difficult  and  slow,  and  the  bowels  less  regular. 
The  slightest  exertion  causes  breathlessness  ;  at  intervals,  sighing, 
groaning,  yawning,  stretching,  and  occasionally,  repeated  fits  of 
sneezing  are  noticed.  Palpitation,  syncope,  sensitiveness  to  exter- 
nal cold,  the  unequal  distribution  of  heat,  a  dry  skin  or  transient 
perspiration,  a  paler  or  deeper  color  of  the  urine  and  inaction  of  the 
genital  organs,  announce  the  approaching  invasion  of  an  acute  af- 
fection. 

In  other  cases,  illness  is  preceded  by  entirely  opposite  phe- 
nomena; the  functions,  far  from  being  enfeebled,  seem  exercised 
with  more  than  ordinary  vigor ;  the  countenance  is  flushed,  the 
strength  increased,  the  intellectual  faculties  more  active,  appetite 
and  digestion  are  more  powerful;  the  individual  congratulates 
himself  upon  his  increased  health,  which  is  but  a  precursor  of 
disease. 

Certain  other  phenomena  have  been  observed  while  disease  was 
still  latent;  one  patient  experiences  a  sensation  which  may  be 
compared  to  that  caused  by  a  breath  of  wind  lightly  fanning  the 
surface  of  the  body;  another,  a  sort  of  shock  similar  to  that  caused 
by  electricity.  Finally,  to  these  phenomena  should  be  added  the 
changes  supervening  in  the  pre-existing  diseases,  in  the  secretion 
from  wounds  or  ulcers,  cauteries,  blisters,  in  the  appearance  of  ex- 
anthemata, etc.  It  is  not  uncommon  to  observe  at  such  times  a 
more  or  less  complete  absorption  of  the  serosity  infiltrated  into  the 
cellular  tissue. 

Such  are  the  principal  phenomena  which  precede  acute  diseases. 


72  SYMPTOMS. 

They  may  be  variously  grouped  and  combined.  Each  of  them 
may  exist  separately.  They  are  never  all  present  in  the  same  in- 
dividual. 

The  duration  of  the  precursory  period  is  very  variable :  occa- 
sionally a  few  minutes,  sometimes  a  number  of  hours ;  it  may 
continue  many  days  or  even  weeks,  but  rarely  longer.  When  it 
has  been  long,  a  grave  disease  may  be  apprehended,  there  are, 
however,  numerous  exceptions  to  this  rule. 

When  the  intensity  of  the  precursory  phenomena  augments  pro- 
gressively, they  may  gradually  become  confounded  with  those  of 
the  disease,  and  likewise  with  the  occasional  causes  which  excite 
its  appearance ;  a  chill,  an  attack  of  indigestion,  the  suppression 
of  an  habitual  evacuation,  the  desiccation  of  an  issue,  are  at  one 
time  the  causes,  at  another  the  first  effects  of  the  disease. 

The  intensity  of  precursory  phenomena  cannot  convey  an  accu- 
rate idea  of  the  gravity  of  the  affection  which  they  announce. 
The  prodrome  of  some  very  severe,  and  even  fatal  diseases,  may  be 
hardly  perceptible;  while  certain  mild  affections  are  sometimes 
preceded  by  inexpressible  anxiety  and  other  very  alarming  signs. 

The  same  phenomena  which  precede  diseases  may  be  manifested 
without  any  subsequent  illness  ;  they  cease  suddenly,  or  gradually 
disappear,  and  the  functions  resume  their  usual  regularity.  —  M. 


CHAPTER  VII, 

SYMPTOMS,*    OR    SYMPTOMATOLOGY. 

A  SYMPTOM  is  any  change  perceptible  to  the  senses,  occurring 
in  any  organ  or  function,  and  connected  with  the  existence  of 
disease. 

Symptoms  should  not  be  confounded  with  phenomena  or  signs. 

A  phenomenon  is  any  act  or  change  effected  in  the  healthy  or 
diseased  body,  whereas,  a  symptom  is  alone  observable  in  the  latter. 
Where  there  is  no  disease,  there  can  be  no  symptom.  Galen 
justly  remarks,  that  the  symptom  follows  the  disease,  as  the 
shadow  follows  the  body.  Hence,  the  impropriety  of  the  terms 
precursory  and  consecutive  symptoms •,  employed  by  many  authors ; 
whatever  is  observable  previous  to  the  existence,  or  after  the  ter- 
mination of  a  disease,  is  a  phenomenon,  not  a  symptom.f 

It  is  equally  important  to  distinguish  between  the  symptom  and 
the  sign.  A  sign,  in  the  common  acceptation  of  the  word,  is  any 

*  Svr,  with,  at  the  same  time  ;  ninrw,  I  fall, 
f  Joyo?,  discourse  ;  ov^nru^ua,  symptom. 


SYMPTOMS.  73 

circumstance,  by  which  we  become  acquainted  with  that  of 
which  we  were  previously  ignorant.  In  medicine,  is  understood 
by  this  word,  whatever  reveals  anything  relating  to  the  past, 
present,  or  future  state  of  a  disease.  The  causes  which  preceded  its 
development,  its  mode  of  attack,  its  progress,  and  the  effect  of 
therapeutical  agents,  all  afford  signs  as  well  as  symptoms.  The 
symptom  is  simply  a  sensation,  which  a  special  effort  of  the  mind 
is  alone  able  to  convert  into  a  sign.  While  the  latter,  therefore, 
relates  to  the  judgment,  the  former  is  referable  to  the  senses.  The 
symptom  is  recognizable  by  every  one,  the  physician  alone  detects 
the  sign  in  the  symptom.  As  there  are  no  symptoms  which  may 
not  furnish  some  sign  to  the  physician,  and  moreover,  as  signs  occur 
in  health  as  well  as  disease,  it  has  been  said,  that  "every  symptom 
is  a  sign,  but  that  all  signs  are  not  symptoms."  By  what  means 
symptoms  are  converted  into  signs  will  be  seen  hereafter :  the 
former  claim  our  present  attention. 

Symptoms,  or  the  appreciable  changes  effected  by  disease  in  the 
various  organs  or  functions,  are  very  numerous.  It  is  important 
that  some  method  be  adopted  in  their  exposition,  by  means  of 
which,  those  between  which  the  greatest  analogy  exists,  may,  as  far 
as  possible,  be  grouped  together.  Several  methods  have  been  pro- 
posed, which  offer  this  advantage  to  a  greater  or  less  extent.  Among 
these  may  be  mentioned  the  division  into  those  symptoms  appre- 
ciable to  the  physician,  and  those  perceptible  to  the  patient ;  that 
also  of  Boerhaave,  who  divided  them  into  three  series,  according 
as  they  depend  upon  disorder  of  the  functions,  excretions,  or  quali- 
ties of  the  body ;  and  finally,  that  recently  proposed  by  Bayle,  our 
former  instructor  and  friend,  who  divided  them  into  vital  and 
physical:  the  former,  which  are  solely  dependent  upon  functional 
disturbance  without  any  appreciable  organic  lesion,  and  which 
disappear  entirely  at  death;  the  latter,  on  the  contrary,  which  con- 
sist in  an  appreciable  change  in  the  parts  themselves,  and  continue 
after  death.  It  will  be  at  once  evident,  that  this  distinction  had 
special  reference  to  pathological  anatomy,  and  was  entirely  inap- 
plicable to  the  methodical  exposition  of  symptoms.  That  pro- 
posed by  Boerhaave,  makes  too  wide  a  separation  between  things 
which  are  nearly  connected ;  the  secretions,  for  example,  are 
separated  from  secreted  matters,  and  the  qualities  of  the  body  from 
the  functions  to  which  they  belong. 

Another  equally  important  point,  is  the  adoption  of  some  order 
which  may  be  advantageously  applied  to  the  history  of  each 
affection,  and  to  the  examination  of  each  particular  patient. 
There  are  many  highly  commendable  practitioners,  who  at  the 
bedside,  examine  in  succession  all  the  functions,  the  organs  of 
which  are  situated  in  the  head,  neck,  chest,  abdomen,  and  limbs ; 
this  method,  which  it  woufd  be  difficult  to  employ  in  the  general 
exposition  of  symptoms,  would  not  present  in  the  examination  of 
individual  patients,  the  same  advantages,  which  might  be  obtained 
from  a  different  one.  It  approximates  things  the  most  unlike,  and 
widely  separates  those,  between  which,  the  greatest  analogy  exists. 


74  SYMPTOMS. 

The  various  disorders  of  the  digestive  organs,  for  example,  in- 
stead of  being  successively  and  uninterruptedly  examined,  are 
separated  from  each  other  by  so  many  intermediate  questions, 
that  it  becomes  difficult  to  discover  the  connection  between  them. 
The  same  may  be  said  of  the  circulation  and  locomotion,  the  or- 
gans of  which  extend  throughout  the  economy,  and  of  many 
other  functions. 

A  more  natural  method  is  to  examine  successively  all  the  de- 
rangements which  each  function  presents,  in  whatever  part  of  the 
body  the  organs  which  concur  in  its  performance  are  situated. 
This  method,  which  is  equally  convenient  in  the  examination  of 
the  patient,  and  in  making  a  record  of  the  disease,  is  the  only  one 
applicable  to  the  particular  description  of  each  affection,  and  to  a 
general  exposition  of  symptoms. 

But  what  order  should  be  pursued,  in  the  examination  of  the 
functions  ?  It  would  be  desirable  if  that  could  be  adopted,  which 
is  generally  followed  in  the  study  of  physiology ;  examining  in 
succession  the  functions  of  assimilation,  those  of  relation,  and 
lastly,  those  of  generation.  As,  however,  this  division  does  not 
present  the  same  advantages  in  the  study  of  the  diseased,  as  in 
that  of  the  healthy  body,  we  think  it  unnecessary  to  confine  our- 
selves strictly  to  it. 

That  which  strikes  the  physician,  in  first  accosting  a  patient, 
and  from  which  he  draws  his  first  conclusions  respecting  the  na- 
ture of  his  disease,  is  the  physiognomy,  attitude,  movements,  and 
voice :  here,  then,  we  should  naturally  commence  our  examination 
of  symptoms ;  it  is,  moreover,  at  this  time  that  the  changes  which 
have  taken  place  upon  the  exterior  of  the  body,  are  more  justly 
appreciated.  If  this  first  sensation  be  neglected,  the  eye  gradu- 
ally becomes  accustomed  to  whatever  is  unusual  in  the  physi- 
ognomy of  the  patient,  and  the  physician  is  rarely  able,  after  re- 
maining with  him  for  a  time,  to  judge  with  the  same  accuracy  as 
he  would  have  done  at  first.  The  same  is  true  of  the  movements 
and  voice ;  it  is  therefore  better  to  commence  the  examination  of 
patients,  and  the  general  exposition  of  symptoms,  with  the  functions 
of  relation,  afterwards  passing  successively  to  those  of  assimila- 
tion and  generation.  We  shall  pursue  the  following  order,  in  the 
exposition  of  the  symptoms  which  belong  to  each  of  these  three 
great  series. 

1.  Exterior  of  the  body.  2.  Digestion. 
Locomotion.  Respiration. 

Voice  and  speech.  Circulation. 

Sensations.  Heat. 

Affective  functions.  Secretions. 

Intellectual  functions.  3.  Generative  functions  in  the  male. 
Sleep  and  the  waking  state.  Generative  functions  in  the  female. 


SYMPTOMS.  75 

ARTICLE  FIRST. 
Symptoms  furnished  by  the  Functions  of  Relation. 

IN  order  to  the  just  appreciation  of  the  changes  effected  by  dis- 
ease in  the  various  functions,  and  particularly  those  of  relation,  it 
is  important,  if  not  indispensable,  that  the  physician  be  familiar  with 
the  physiognomy,  attitude,  gestures,  and  voice  of  persons  in  health. 
Without  this  fixed  point  of  comparison,  he  will  be  unable  to 
arrive  at  more  than  approximate  results,  in  his  appreciation  of  the 
phenomena  which  fall  under  his  observation. 

SECTION    FIRST. 
Symptoms  furnished  by  the  Exterior  of  the  Body.  • 

THE  symptoms  which  may  be  presented  by  the  exterior  of  the 
body,  are  of  the  highest  importance.  Having  first  considered 
those  presented  by  the  body  as  a  whole,  we  shall  pass  to  the 
consideration  of  those  which  may  be  furnished  by  each  part  re- 
spectively. 

$  I.  The  exterior  of  the  body,  considered  generally,  comprises  the 
attitude,  volume  of  the  body,  firmness  of  the  flesh,  color  of  the 
skin,  eruptions,  plicatures.  tumors,  and  solutions  of  continuity  of 
every  kind.  To  these  might  be  added,  the  heat  and  moisture  of 
the  skin,  pulsations  of  superficial  arteries,  distension  of  veins, 
&c. ;  but  these  will  be  more  naturally  considered  elsewhere. 

A.  In  health,  the  attitude  in  the  waking  state  is  free  and  un- 
constrained ;  during  sleep,  the  limbs  are  usually  demiflexed,  and 
the  body  inclined  to  one  side,  commonly  the  right.  In  disease, 
the  attitude  varies  more  or  less  from  these  conditions. 

If  the  patient  be  up,  an  unusual  degree  of  languor  is  observable 
in  his  attitude;  in  some  cases,  as  in  maniacs,  for  example,  an 
unnatural  degree  of  strength  and  assurance  is  noticed.  There  are 
some  diseases  which  are  at  once  recognizable  from  the  position 
of  the  patient ;  as  catalepsy,  for  example,  from  the  general  immo- 
bility ;  St.  Vitus'  dance,  from  the  irregularity  and  continual  suc- 
cession of  motions ;  hemiplegia,  from  distortion  of  the  features, 
and  a  change  in  the  position  and  motions  of  the  limbs,  and 
opisthotonos  and  emprosthotonos,  from  the  convulsive  flexion  of 
the  body  backward  and  forward. 

When  in  bed,  some  patients  assume  various  postures,  and  retain 
them  for  a  time ;  others  are  constrained  to  remain  in  the  same 
position,  a  symptom  not  without  importance.  Thus  some  patients 
lie  constantly  upon  the  back,  (decubitus  dorsal)  either  from  debil- 
ity, which  occurs  in  adynamic  fevers,  or  from  difficulty  or  pain 


76  SYMPTOMS. 

experienced  when  in  any  other  posture,  as  is  the  case  in  general 
rheumatism,  and  acute  peritonitis.  Others,  from  the  nature  and 
violence  of  their  pains,  are  compelled,  at  least  for  a  time,  to  lie 
upon  the  abdomen,  as  in  saturnine,  nephritic  and  hepatic  colic,  and 
in  some  cases  of  delirium.  At  times  the  patient  lies  upon  one  and 
the  same  side,  (decubitus  lateral)  in  consequence  of  effusion  into 
one  of  the  pleurae,  inflammation  of  one  lung,  or  an  acute  pain  on 
either  side;  in  cases  of  effusion  or  hepatization  the  patient  lies 
upon  the  affected  side,  and  upon  the  opposite  side  when  suffering 
from  acute  pain.  There  are  however  numerous  exceptions  to  these 
rules,  the  dorsal  decubitus  being  the  posture  most  frequently 
observed  in  cases  of  pleuritic  effusion,  and  single  pneumonia. 
Lastly,  in  certain  thoracic  affections  attended  with  difficulty  of 
respiration,  and  particularly  in  cardiac  aneurism,  in  double  hydro- 
thorax,  and  in  the  paroxysm  of  dyspnoea  occurring  in  pulmonary 
emphysema,  the  patient  is  compelled  to  sit  up  in  bed,  it  being 
impossible  for  him  to  retain  the  horizontal  position  ;  he  is  even  in 
some  cases  obliged  to  bend  forward,  in  order  to  create  a  support, 
allowing  the  legs  to  hang  down.  In  some  affections  of  the  air 
passages,  the  patient  retains  the  sitting  posture,  with  the  head 
thrown  backward.  In  compression  of  the  trachea  by  a  tumor, 
particularly  if  it  be  an  aortic  aneurism,  the  patient  is  constrained 
to  assume  a  fixed  and  often  strange  attitude,  this  position  doubtless 
partially  relieving  the  pressure  upon  this  organ,  and  thereby 
rendering  respiration  less  difficult.  In  other  diseases,  instead  of 
being  constantly  confined  to  one  position,  the  patient  is  obliged  to 
change  it  continually.  This  state  of  restlessness  (inquies)  is  par- 
ticularly observable  in  inflammations  of  the  abdomen,  and  at  the 
commencement  of  eruptive  fevers. 

B.  The  body  becomes  increased  or  diminished  in  volume  in 
many  diseases. 

A  slight  increase  of  volume  occurs  in  febrile  heat,  and  in  the 
second  stage  of  intermittent  fever ;  while  in  the  first  or  cold  stage 
diminution  takes  place.  Plethora  produces  an  analogous  effect, 
appreciable  in  the  face,  hands,  and  particularly  the  fingers,  which 
are  with  difficulty  flexed.  A  more  marked  tumidity  occurs  at  the 
commencement  of  the  exanthematous  diseases.  But  where  con- 
siderable increase  of  volume  exists,  it  is  almost  always  owing  to 
an  accumulation  of  fat  or  serous  fluid  in  the  cellular  tissue,  and 
is  sometimes  caused  by  the  passage  of  air  between  its  lamellae. 

The  accumulation  of  fat,  and  the  consequent  increase  in  the 
volume  of  the  body,  have  been  rarely  observed  in  disease.  They 
may  occur  in  certain  local  affections,  which  compel  the  patient  to 
abstain  from  exercise,  and  in  which  a  subjection  to  regimen  is 
unnecessary.  This  accumulation,  when  considerable,  is  itself  a 
disease,  which  has  been  designated  by  the  term  adipose  polysarcia. 

Increase  in  the  volume  of  the  body  when  occurring  in  disease, 
is  almost  always  owing  to  infiltration  of  serum  into  the  interstices 
of  the  cellular  texture.  This  infiltration,  when  general,  is  called 


SYMPTOMS.  77 

anasarca  #  or  leucophlegmasia,  f  and  when  partial,  oedema.  J  It 
is  known  by  the  paleness  and  semi-transparency  of  the  skin,  and 
by  its  pitting  on  pressure  of  the  finger.  This  depression  however, 
to  be  perceptible,  often  requires  that  the  finger  be  passed  lightly 
over  it,  when  it  is  at  once  felt.  (Edematous  swelling  may  be 
more  easily  recognized,  when  the  disposition  of  the  skin  allows  us 
to  pinch  it  between  the  fingers.  Incipient  osdema  may  be  often 
thus  distinguished  in  patients  confined  to  their  beds,  on  the  inter- 
nal surface  of  the  thighs;  in  those  who  are  up.  oedema  first  shows 
itself  around  the  malleoli,  particularly  towards  evening. 

The  infiltration  of  air  into  the  cellular  tissue,  is  called  emphyse- 
ma. ||  It  occurs  in  penetrating  wounds  of  the  thorax,  and  in 
diseases  in  which  the  continuity  of  the  air  passages  is  destroyed  :  it 
is  owing  in  both  cases  to  the  introduction  of  air  into  the  interstices 
of  the  cellular  texture.  That  which  occurs  in  gangrenous  affec- 
tions seems  to  depend  upon  the  rapid  decomposition  of  parts 
already  deprived  of  life.  The  insufflation  of  air  into  the  cellular 
tissue  produces  artificial  emphysema.  Can  we  admit  with  some 
authors,  the  existence  of  spontaneous  emphysema,  produced  by 
exhalation  of  gas  into  the  cellular  tissue  ?  Without  pretending  to 
assign  a  limit  to  possibilities,  we  are  of  opinion  that  in  the  present 
state  of  the  science,  such  exhalation  cannot  be  certainly  proved. 
Emphysema,  whatever  be  its  origin,  is  easily  recognized,  particu- 
larly in  gangrenous  diseases,  by  the  crepitation  produced  by  pres- 
sure upon  the  tumified  parts,  by  the  softness  and  elasticity  of  the 
distended  integuments  which  readily  yield  under  the  finger  with- 
out preserving  the  impression,  and  by  increased  resonance. 

Diminution  in  the  volume  of  the  body  is  a  very  frequent  phe- 
nomenon in  disease.  It  may  in  the  course  of  a  few  days,  and 
even  a  few  hours,  become  considerable,  as  after  one  or  two 
paroxysms  of  malignant  intermittent  fever,  or  after  excessive 
alvine  discharges,  as  was  observed  by  Morgagni  on  his  own  person, 
in  an  attack  of  serous  diarrhoea,  and  as  we  have  ourselves  frequent- 
ly remarked  in  Asiatic  cholera ;  but  it  usually  takes  place  slowly, 
constituting  emaciation,  which  may  exist  in  different  degrees  from 
simple  emaciation,  to  marasmus.  $  In  most  acute  diseases,  there  is 
little  diminution  of  volume,  unless  they  be  prolonged  or  accompa- 
nied with  abundant  evacuations,  or  treated  by  artificial  evacuants, 
as  bleeding,  purgatives,  &c.  With  these  exceptions,  emaciation 
does  not  become  very  apparent  in  acute  affections  till  the  period  of 
convalescence.  It  is  particularly  in  chronic  diseases  that  it  be- 
comes considerable,  and  in  such  cases  is  always  indicative  of  great 
danger. 

C.     During  the  period  of  growth,  in  the  course  of  acute  and 

*''Ava,  in  ;   &-a££,   flesh. 

f  Jtvxo?,  white  ;  y*«y<««0<a,  inflammation. 
|  Oi<V«i  swelling. 
||  'Eutpvaato,  I  inflate. 
<S  JUapau'w,   I  dry  up. 

7* 


78  SYMPTOMS. 

chronic  diseases,  increase  in  height  is  sometimes  observed  to  he  far 
more  rapid  than  ordinarily  takes  place  in  health.  This  sudden 
growth  is  generally  a  suspicious  sign. 

D.  The  firmness  of  the  flesh  demands  attentive  consideration 
in  diseases.     Huxham,  and  many  other  distinguished  physicians, 
have  attached  due  importance  to  this  symptom,  with  reference  to 
the  appreciation  of  the  strength,  in  acute  diseases.     It  is  preserved 
and  even  augmented  in  most  inflammatory  affections;  and  is  sen- 
sibly diminished  in  diseases  of  debility.     Flaccidity  of  the  flesh  is 
particularly  noticed  in  the  adynamic  diseases. 

E.  The  color  of  the  skin  varies  according  to  the  climate,  sex, 
age, 'habitual  occupations,  &c. ;  there  is  however  a  tint  peculiar  to 
health  which  is  familiar  to  every  one.     There  are  some  slight 
affections  in  which  the  color  of  the  skin  remains  unchanged ;  but 
in  nearly  all  grave  diseases,  there  is  a  perceptible  change  in  the 
natural  color  of  this  membrane. 

The  skin  is  pale  in  the  cold  stage  of  intermittent  fevers ;  and  in 
cases  of  scrofula,  chlorosis,  anemia  and  in  certain  species  of  dropsy, 
it  also  has  a  semi-transparent  appearance.  It  is  sallow  and  en- 
crusted, as  it  were,  with  an  earthy  substance  in  adynamic  diseases, 
particularly  in  the  last  stage  of  grave  and  epidemic  dysenteries, 
and  often  also  in  phthisis  pulmonalis.  It  becomes  of  a  livid  hue 
in  persons  of  full  habit  when  chilled,  in  scurvy,  diseases  of  the 
heart,  and  certain  chronic  inflammations  of  the  intestinal  canal. 
In  most  of  these  affections  the  lividity  is  more  apparent  in  some 
parts  than  others,  as  about  the  lips, -eyes  and  fingers.  The  skin 
is  of  a  rosy  hue  in  inflammatory  fevers,  and  just  previous  to  the 
development  of  general  ^eruptions,  it  is  of  a  bright  red  color  in 
scarlatina.  It  presents  a  yellowish  tint  in  certain  bilious  affec- 
tions ;  is  of  a  dull  yellow  color  in  intermittent  fevers  when  of  a 
certain  duration,  of  a  pale  yellow  or  earthy  appearance  in  cancer, 
and  of  a  citron  or  deep  yellow  color  in  jaundice ;  it  becomes  of  a 
bluish  tint  in  those  suffering  under  the  severest  form  of  Asiatic 
cholera.  The  same  is  observed  in  certain  organic  affections  of  the 
heart;  this  singular  discoloration  is  called  cyanosis.*  This  has 
generally  been  attributed  to  malformation  of  the  heart,  which 
allows  the  blood,  at  least  a  portion  of  it,  to  pass  from  the  right  to 
the  left  side  of  the  heart,  without  first  traversing  the  lungs.  But 
cyanosis  is  often  independent  of  every  such  lesion,  and  even  in  the 
cases  in.  which  there  is  permanent  patency  of  the  foramen  Botale, 
it  is  evident  that  this  affection  cannot  be  referred  to  admixture  of 
the  two  fluids,  as  this  phenomenon  sometimes  fails  in  cases  where 
the  heart  being  unilocular,  the  pulmonary  artery  and  aorta  have  a 
common  origin.  Cyanosis  seems  to  depend  on  a  stagnation  of 
blood  in  the  capillary  vessels,  produced  by  some  obstacle  to  its 
circulation  through  the  lungs  and  heart;  it  is' observed  in  different 

*  Kvaiog,  blue. 


SYMPTOMS.  79 

degrees,  in  most  organic  diseases  of  this  viscus,  and  particularly 
in  contraction  of  its  orifices,  in  certain  forms  of  pulmonary  em- 
physema, and  general  or  capillary  bronchitis,  and  lastly,  in  some 
cases  of  rachitis,  in  which  there  is  considerable  deformity  of  the 
thorax.  In  these  different  diseases,  cyanosis  is  generally  partial, 
affecting  usually  the  face,  particularly  the  cheeks  and  lips,  the 
hands,  principally  about  the  nails  and  the  pulp  of  the  fingers,  and 
(in  thejnale)  the  genital  organs,  becoming  more  marked  in  all  these 
parts  when  general.  *  We  have  observed  a  greenish  tint  in  the 
skin  of  an  anemic  patient  who  appeared  to  labor  under  an  affec- 
tion of  the  liver.  The  skin,  in  some  individuals,  accidentally 
becomes,  from  the  influence  of  some  unknown  cause,  of  a  blackish 
or  brownish  color.  This  was  the  case  with  a  patient  who  spent 
several  months  at  the  Hospital  de  la  Charite,  whose  skin,  naturally 
white,  became  almost  as  black  as  that  of  a  negro,  f  Several 
similar  cases  have  been  observed  and  published  by  M.  Rostan.  J 

In  connection  with  these  cases  may  be  mentioned  those,  in 
which  the  blackish  or  bluish  color  is  owing  to  a  coloring  matter 
which  transudes  through  the  skin,  a  very  curious  example  of 
which  is  given  by  Billard.  || 

Lastly,  it  is  well  known  that  the  internal  use  of  nitrate  of  silver, 
when  long  continued,  produces  in  the  skin  a  bronze  or  slate  color 
which  is  indelible.  It  has  been  supposed  that  the  light  exerted  a 
great  influence  in  its  production ;  but  to  us  this  does  not  appear  a 
satisfactory  explanation.  We  believe  that  light  has  the  prop- 
erty of  increasing  the  color,  but  is  not  the  sole  agent  in  its  produc- 
tion ;  for  this  brown  tint  appears  in  parts  of  the  body  which  are 
shielded  from  it  by  clothing,  as  well  as  in  those  parts  which  are 
exposed  to  its  influence ;  it  is  also  found  to  exist  in  internal  organs. 

The  skin  presents,  in  some  cases,  red,  black,  bluish  or  yellow 
spots  called  ecchymoses,  which  are  caused  by  extravasation  of 
blood ;  they  are  often  produced  by  contusions,  pressure  and  other 
external  causes  ;  and  are  sometimes  owing  to  a  cachectic  state  of 
the  system,  as  in  scurvy  and  morbus  maculosus. 

Spots  of  a  livid,  brown  or  blackish  tint,  are  sometimes  observed 
in  the  course  of  acute  diseases,  generally  appearing  upon  the  most 
depending  parts,  and  constituting  an  unfavorable  sign.  These 
spots  have  been  sometimes  confounded  with  ecchymoses,  but  are 
generally  rather  the  result  of  stagnation  than  extravasation  of 
blood,  as  they  momentarily  disappear  under  pressure.  Eschars 
and  excoriations  are  also  formed  upon  various  parts  of  the  surface 
of  the  body,  and  particularly  those  upon  which  the  body  rests,  as 
the  region  of  the  sacrum  and  trochanters.  This  phenomenon  is 
of  more  frequent  occurrence  in  typhoid  than  in  other  acute  affec- 
tions, and  its  appearance  in  obscure  cases  is  an  important  diag- 
nostic sign. 

*  Dictionaire  de  Mrdecine  t.  ix.  Cyanose,  par  FERRUS  ;  et  Louis  Memoires 
anat-pathol.,  ou  Archives  de  1823. 

f  Bulletin  de  la  Faculte,t.  iv.,  p.  114. 

j  Idem. 

||  Archives  de  Medecine  t.  xxvi.,  p.  453. 


80  SYMPTOMS. 

The  skin  may  undergo  modifications  of  more  or  less  importance 
in  disease,  which  are  appreciable  to  the  touch.  Instead  of  remain- 
ing pliant  and  soft  as  in  health,  it  often  becomes  dry  and  rough, 
as  in  the  first  stages  of  acute  affections,  and  in  chronic  diseases. 
This  roughness  and  dryness  becomes  still  more  marked  during 
convalescence  from  certain  eruptive  diseases,  as  rubeola  and 
variola.  After  scarlatina  it  is  dry,  smooth  and  shining,  as  if  cov- 
ered with  goldbeater's  skin ;  this  state  of  the  skin  which  is  more 
apparent  in  the  hands,  enables  the  physician,  even  before  otesqua- 
mation  has  commenced,  to  decide  upon  the  previous  existence  of 
scarlatina.  In  Asiatic  cholera,  the  skin  in  various  parts  of  the 
body,  particularly  upon  the  back  of  the  hands  and  forearms,  strik- 
ingly resembles  parchment.  When  pinched  between  the  fingers 
it  forms  a  fold  which  retains  its  form  for  some  minutes ;  in  this 
affection  also,  the  palmar  surfaces  of  the  fingers  present  inequal- 
ities, similar  to  those  which  are  produced  in  the  same  parts,  after 
their  prolonged  immersion  in  water. 

F.  The  skin  is  the  seat  of  various  eruptions.     These  have 
been    distinguished  by  the   terms  exanthemata,  vesicula,   bullse 
pustules,  papulae,  squamae,  tubercula  and  maculae.     Exanthemata 
are  reddish  spots,  with  or  without  prominence,  which  vary  in  size, 
form,  and  degree  of  color,  and  which  disappear  on  pressure  of  the 
finger.     Vesicula  are  small  elevations  of  the  epidermis,  formed  by 
a  collection  of  serous   and   transparent  fluid  which  sometimes 
becomes  opaque.     Bullae  differ  from  the  latter  only  in  their  size, 
which   is   not  less   than  that  of  a  pea,    while  vesicles   do   not 
exceed  that  of  a  millet  seed.     Pustulae  are  small  tumors   filled 
with  pus,    developed  upon   the   surface  of  the  inflamed  corpus 
mucosum.     Papulae  are  small  hard  elevations  which  contain  no 
fluid,  but  are  susceptible  of  ulceration.     Squamae  are  small  laminae 
of  epidermis  generally  thickened,  dry,  whitish  and  friable,  which 
surmount  small  elevations  resembling  papules.     The  name  tuber- 
cula has,  in  cutaneous  pathology,  been  applied   to  small,  hard, 
circumscribed  and  permanent  tumors,  susceptible  of  ulceration  or 
partial  suppuration.     Maculae  are  colorations  or  permanent  discol- 
orations  of  certain  portions  of  the  skin,  or  of  the  whole  cutaneous 
envelope,  unattended  with  general  constitutional  disturbance.  * 

G.  Plicatures  are  impressions  made  upon  the  skin  by  the  con- 
tact of  bedclothes,  or  clothing.     When   occurring  in  health,  they 
are  superficial,  of  a  rosy  color,  and  readily  disappear.     In  certain 
diseases,    they   are   deep,    lasting,  of  a  livid  or  bluish   tint,  and 
sometimes  excoriated.      Vibices  (vibices)  are  a  species  of  plicature, 
although  in  some  cases  they  are  but  varieties  of  urticaria. 

H.     To  these  symptoms  furnished  by  the  exterior  of  the  body, 

*  Abregt  pratique  des  Maladies  de  la  Peau,  d  'apres  les  lemons  du  docteur  Bietl 
par  Alph.  Cazenave  et  Schedel.  3d  edit. 


SYMPTOMS.  81 

may  be  added  tumors,  excoriations,  fissures,  wounds,  ulcers  and 
fistulge,  which  may  appear  on  any  part  of  the  body.  Tumors 
(tumores)  consist  of  a  partial  increase  in  the  natural  size  of  any 
part ;  they  vary  in  form,  mode  of  increase,  consistence  and  in  their 
constituent  parts.  Some  disappear  under  certain  circumstances,  and 
particularly  under  the  influence  of  pressure  ;  others  convey  to  the 
fingers  a  feeling  of  fluctuation  owing  to  the  presence  of  a  fluid 
which  they  contain ;  others,  as  certain  hsemorrhoidal  tumors,  are  en- 
dowed with  a  kind  of  erectility.  An  excoriation  is  the  appearance 
presented  by  the  skin  when  deprived  of  its  epidermis,  and  the  most 
superficial  layers  of  the  corion ;  it  occurs  in  grave  diseases,  and 
commonly  precedes  the  formation  of  eschars. 

Fissures  (fissura)  is  the  name  given  to  those  solutions  of  con- 
tinuity which  occur  in  different  parts  of  the  body,  and  which 
seem  by  their  elongated  and  narrow  form,  to  result  from  excessive 
distension  of  the  skin :  they  are  generally  owing  to  syphilitic  virus 
or  certain  eruptions ;  they  appear  on  the  back  of  the  hand,  but 
more  frequently  at  the  points  of  junction  of  the  skin  and  mucous 
membranes,  as  about  the  nose,  lips,  nipples  and  orifice  of  the 
rectum.  Ulcers  (ulcera)  are  solutions  of  continuity  depending 
upon  some  constitutional  or  local  disease.  Of  these,  there  are 
numerous  varieties  according  to  the  elevation  of  their  edges,  color 
of  the  ulcerated  surface,  and  phenomena  which  generally  accom- 
pany them.  Fistulce.  are  accidental  canals  which  convey  away, 
sometimes  matters  contained  in  natural  canals,  and  sometimes  the 
product  of  a  morbid  exhalation. 

$  II.  The  head,  considered  as  a  whole  and  with  reference  to  po- 
sition and  size,  furnishes  some  remarkable  symptoms. 

It  is  inclined  laterally  in  convulsions,  paralysis  of  the  muscles 
of  one  side,  torticollis,  dislocation  of  the  vertebrae  and  certain 
engorgements  of  the  cervical  glands ;  it  is  strongly  bent  backward 
in  croup  and  in  some  diseases  accompanied  by  dyspnoea ;  it  is  in- 
clined forward  in  cases  of  vertebral  malformation. 

The  portion  of  the  head  corresponding  to  the  cranium  is  the  seat 
of  many  important  symptoms.  Its  volume  is  increased  in  congen- 
ital hydrocephalus.  The  hairy  scalp,  when  affected  with  erysipelas, 
becomes  aedematous,  with  extreme  sensibility  to  pressure.  These 
two  phenomena  are  particularly  important,  as  the  redness,  which  is 
the  principal  sign  of  the  disease  in  other  parts  of  the  body,  is  rarely 
observed  in  this  variety. 

In  idiots,  the  forehead  is  generally  low.  narrow  and  receding ; 
or  the  occiput  may  be  flattened  and  directed  vertically  towards  the 
summit  of  the  head.  In  some  cases  the  two  sides  of  the  cranium 
are  not  symmetrical,  one,  generally  in  the  parietal  region,  being 
more  or  less  depressed.  The  cranium  may  present  tumors  which 
are  developed  either  in  one  of  its  bones,  in  the  surrounding  integ- 
uments, or  in  the  substance  contained  within  it.  Its  integuments 
are  the  peculiar  seat  of  certain  eruptions,  as  crusta  lactea  and  tinea. 

The  symptoms  furnished  by  the  face  are  extremely  numerous, 
of  which  the  most  important  and  difficult  of  exposition  are  those 


SYMPTOMS. 


presented  by  the  physiognomy.  This  in  health  is  characterized,  as 
has  been  remarked  by  Chaussier,  by  vigor  and  alacrity,  and  its 
expression  is  in  harmony  with  surrounding  objects.  The  various 
shades  of  expression  which  the  physiognomy  is  capable  of  present- 
ing under  morbific  influence,  it  would  be  impossible  to  describe ; 
it  may  appear  sad,  dejected,  uneasy,  terrified,  indifferent  or  atten- 
tive, sometimes  smiling,  at  others  menacing  or  wandering,  without 
there  being  any  circumstance  to  account  for  these  modifications  of 
the  features,  which  consequently  should  be  classed  among  the 
morbid  phenomena. 

The  natural  symmetry  of  the  two  sides  of  the  face  is  destroyed 
in  cases  of  complete  hemiplegia.  and  in  paralysis  of  the  nerves  of  the 
seventh  pair.  The  paralyzed  side  loses  all  expression,  while  the 
natural  appearance  of  the  sound  side  is  retained  ;  there  is  manifest 
deviation  of  the  mouth,  its  commissures  being  drawn  down  and 
towards  the  median  line ;  the  cheek  is  flaccid,  and  the  eyelids  are 
no  longer  capable  of  covering  the  eye ;  the  eyebrow  is  depressed, 
and  the  forehead  free  from  its  natural  wrinkles.  All  these  differ- 
ences become  still  more  marked,  when  the  muscles  of  the  sound 
side  are  strongly  contracted,  particularly  in  the  effort  of  laughing. 
If  the  disease  be  of  long  standing,  the  nose  becomes  affected. 

Among  the  numerous  alterations  of  the  countenance  effected  by 
disease,  some  have  received  distinctive  appellations ;  as  stupor 
(fades  stupida),  the  injected,  pinched,  and  hippocratic  countenance. 
It  has  also  been  observed  that  diseases  of  the  brain,  chest,  and 
abdomen  so  modify  the  countenance  as  to  enable  the  physician,  in 
many  instances,  to  determine  from  its  inspection  the  seat  of  the 
disease. 

Stupor  is  distinguished  by  a  want  of  expression  of  the  features 
generally,  and  particularly  the  eyes;  the  patient  appears  uncon- 
scious of  what  is  going  on  around  him,  and  incapable  of  reflection, 
as  if  in  a  state  of  intoxication.  This  expression  of  face  is  peculiar 
to  typhoid  disease. 

The  fades  vultuosa  is  characterized  by  fulness  and  redness  of  the 
part,  prominence  of  the  eyes,  injection  of  the  conjunctives,  disten- 
sion of  the  eyelids  and  lips,  and  fulness  of  all  the  features.  This 
is  particularly  observed  in  hypertrophy  of  the  heart,  and  in  some 
cases  of  cerebral  congestion. 

The  pinched  countenance,  which  belongs  to  acute  peritonitis,  pre- 
sents the  opposite  characteristics ;  the  face  appears  diminished  in 
size,  of  a  pale  or  livid  hue,  its  muscles  contracted,  and  the  features 
drawn  upward  or  towards  the  median  line.  Exposure  to  severe 
cold  produces  analogous  effects  in  healthy  persons. 

The  hippocratic  countenance  has  been  so  called  from  Hippo- 
crates, who  first  pointed  out  its  peculiar  characteristics.  It  is 
observable  in  patients  suffering  from  chronic  disease,  a  few  days 
before  death,  and  in  some  cases  of  prolonged  acute  disease.  Its 
principal  features  are  the  pinched  nose,  sunken  eyes,  hollow  tem- 
ples, cold  and  retracted  ears,  dryness  and  tensity  of  the  skin  of  the 
forehead,  livid  complexion,  and  cold  and  relaxed  lips ;  such  are 


SYMPTOMS.  83 

the  sure  harbingers  of  death,  unless  there  be  some  manifest  cause, 
as  excessive  watchfulness,  obstinate  diarrhoea,  or  prolonged  absti- 
nence, to  account  for  such  an  appearance. 

Diseases  of  the  head  are  far  from  impressing  upon  the  physiogno- 
my uniform  characteristics ;  the  same  is  true  of  thoracic  and  ab- 
dominal diseases.  There  are,  however,  numerous  affections  of  the 
organs  contained  within  these  cavities,  in  which  the  appearance  of 
the  countenance  is  characteristic.  The  appearance  of  sleep,  con- 
vulsions of  the  facial  muscles,  lateral  paralysis,  an  expression  of 
fury  or  joy,  are  indicative  of  a  primary,  or  secondary  lesion  of  the 
brain ;  fulness  of  the  face  or  neck,  together  with  a  whistling 
sound  in  the  larynx,  or  convulsive  efforts  at  deglutition  or  expec- 
toration, clearly  denote  some  form  of  angina.  There  is  a  peculiar 
alteration  in  the  face  noticeable  in  diseases  of  the  heart,  and  in 
phthisis  pulmonalis,  though  in  the  latter  it  is  less  apparent.  The 
pinched  face,  as  has  been  remarked,  is  peculiar  to  peritonitis,  and 
most  abdominal  diseases  of  an  organic  nature  are  discoverable  by 
their  effect  upon  the  countenance  of  the  patient. 

M.  Jadelot  thought  he  observed  in  children,  a  constant  corres- 
pondence, between  diseases  of  the  head,  chest,  and  abdomen,  and 
certain  alterations  in  the  physiognomy,  differing  from  those  just 
mentioned.  The  following,  appeared  in  a  work  published  under 
the  supervision  of  this  physician.*  In  the  face  of  the  child  three 
principal  features  are  observable ;  the  first,  extending  from  the 
external  angle  of  the  orbit  of  the  eye,  to  a  little  below  the  promi- 
nence formed  by  the  malar  bone ;  this  may  be  called  the  ocitlo- 
zygomatic  ;  the  second  commences  at  the  superior  part  of  the 
ala  nasi,  and  embraces  in  a  semicircle,  more  or  less  complete,  the 
external  line  of  the  commissure  of  the  lips  ;  this  is  the  nasal  feature 
to  which  another  sometimes  extends,  from  the  middle  of  the  cheek 
called  genal ;  the  last  commences  at  the  angle  of  the  lips,  and 
terminates  at  the  lower  part  of  the  face,  which  may  be  called  the 
labial  feature.  The  first  indicates  affections  of  the  brain  and  ner- 
vous system ;  the  second  and  its  accessory  point  out  those  of  the 
abdominal  viscera;  the  third  appertains  to  diseases  of  the  heart 
and  respiratory  organs. f 

The  face  furnishes  still  other  symptoms  relative  to  changes  in 
its  motions,  size,  color,  and  the  eruptions  of  which  it  is  the  seat. 

Convulsive  movements  of  the  face  are  observed  in  incipient  teta- 
nus, permanent  immobility  in  some  nervous  diseases,  and  transient 
tremors  in  typhus  fever ;  in  some  cases  of  cerebral  compression,  the 
paralysis  is  confined  to  the  muscles  of  this  region. 

The  face  rarely  becomes  increased  or  diminished  in  volume, 
without  the  occurrence  of  a  similar  change  in  other  parts  of  the 

*  Maladies  des  Enfans  cT  Underwood,  publiees  par  M.  de  Salles,  avec  des  notes 
de  M  Jadelot. 

f  We  refrain  from  all  conclusions  upon  the  value  of  these  signs  ;  first,  because 
our  observations  upon  this  point  have  been  thus  far  too  limited  to  enable  us  us  to 
form  an  opinion  ;  and  second,  because  the  result  of  these  observations  would  not 
conform  to  the  opinion  of  M.  Jadelot. 


84  SYMPTOMS. 

body ;  partial  turgescence  of  this  region,  however,  is  common  at 
the  commencement  of  eruptive  fevers,  and  sometimes  just  previous 
to  nasal  or  cerebral  haemorrhage.  It  may  be  also  remarked  that 
in  those  cases  in  which  increase  or  diminution  in  volume  of  the 
whole  body  occurs,  these  changes  are  perceptible  in  the  face  before 
becoming  so  in  other  parts. 

In  disease,  the  same  changes  occur  in  the  color  of  the  face  as  in 
that  of  other  parts;  it  also  undergoes  modifications  which  do  not 
extend  to  the  rest  of  the  cutaneous  surface.  Redness  of  the  face  is 
a  very  frequent  symptom ;  it  may  affect  its  whole  surface  or  be 
confined  to  a  particular  part.  The  face  is  of  a  bright  red  color  in 
the  paroxysms  of  acute  diseases,  of  a  deep  and  livid  red  in  those 
of  hysteria  and  epilepsy,  and  the  difficulty  of  distinguishing 
between  the  two  latter  affections  is  partly  owing  to  this  circum- 
stance ;  in  hysteria,  however,  the  face  does  not  present  the  same 
hideous  aspect  as  in  epilepsy,  and  this,  according  to  M.  Landre 
Beauvais,  is  perhaps  the  most  important  sign  in  the  diagnoses  of 
these  two  affections.  The  face  is  occasionally  the  seat  of  a  tran- 
sient redness,  commonly  known  as  feux  au  visage  ;  this  is  partic- 
ularly observable  in  females  suffering  from  menstrual  irregularity, 
or  at  the  critical  age.  The  seat  of  the  redness  during  the  febrile 
paroxysm  and  in  chronic  diseases,  is  the  malar  region.  It  is  some- 
times confined  to  one  cheek,  a  phenomenon  formerly  considered  as 
connected  with  an  acute  or  chronic  affection  of  the  corresponding 
lung;  but  it  generally  depends  upon  the  position  of  the  patient 
when  in  bed,  the  cheek  which  rests  upon  the  pillow  being  redder 
than  that  of  the  opposite  side.  A  bright  and  circumscribed  redness 
in  the  malar  regions,  together  with  paleness  of  the  rest  of  the  face, 
is  a  frequent  symptom  in  tubercular  affections.  The  yellowness 
which  characterizes  jaundice  is  generally  perceptible  in  the  face, 
and  particularly  in  the  sclerotics,  before  appearing  elsewhere ;  it 
also  remains  apparent  in  these,  after  its  entire  disappearance  in 
other  parts  of  the  body.  In  some  bilious  affections,  the  yellow 
tint  is  confined  to  the  labial  commissures  and  alae  nasi. 

There  are  certain  eruptions  which  are  peculiar  to  the  face; 
during  the  period  of  youth  the  forehead  often  becomes  the  seat  of 
a  papular  eruption  which  commonly  disappears  before  the  age  of 
twenty-five.  In  adults,  towards  the  decline  of  ephemeral  fevers 
and  slight  acute  inflammatory  affections,  the  lips  become  affected 
with  an  herpetic  eruption.  Every  part  of  the  face  furnishes 
numerous  symptoms,  which  we  shall  briefly  enumerate. 

In  health,  the  eyes  are  moderately  prominent,  moist,  brilliant, 
moving  with  facility,  and  both  directed  to  the  same  object;  the 
white  portion  of  the  eye  is  smooth,  unstriated,  and  of  its  natural 
color  ;  the  pupils  of  both,  dilate  and  contract  promptly  and  equally ; 
the  eyelids  are  thin,  moveable,  equally  separated  during  the 
waking  state,  and  entirely  cover  the  eye  during  sleep;  the  eye- 
brows are  slightly  arched.  Under  the  influence  of  disease,  the 
globe  of  the  eye  and  the  parts  which  protect  it,  present  remarka- 
ble changes. 


SYMPTOMS.  85 

The  expression  of  the  eyes  often  corresponds  with  that  of  the  rest 
of  the  face:  it  may  be  mild,  suppliant,  threatening,  haggard,  orter-' 
rifled ;  but  sometimes  in  the  disturbance  which  accompanies  malig- 
nant fevers  and  the  cerebral  phlegmasise,  their  expression  is  in 
contrast  with  that  of  the  physiognomy. 

The  changes  observed  in  the  movements  of  the  eye  are  generally 
connected  with  some  primary  or  secondary  lesion  of  the  brain. 
The  eyes  are  fixed  in  catalepsy,  and  in  the  ecstasy  of  melancho- 
lies ;  their  motions  are  convulsive  in  the  hydrocephalus  of  children  : 
strabismus  or  divergence  of  the  optic  axes,  when  occurring  acci- 
dentally, is  almost  always  the  effect  of  cerebral  disease. 

There  is  another  very  remarkable  phenomenon,  resembling 
ordinary  strabismus,  but  differing  from  it  in  some  respects ;  we 
refer  to  the  isolated  movement  of  one  eye,  the  other  remaining 
totally  immovable ;  we  witnessed  the  repeated  occurrence  of  this 
phenomenon  in  a  case  of  hemiplegia  in  a  child  from  ten  to  twelve 
years  of  age,  succeeding  epileptiform  convulsions  which  were 
probably  connected  with  some  organic  lesion  of  the  brain.  This 
symptom,  together  with  a  state  nearly  comatose,  had  excited  fears 
which  were  not  however  realized. 

The  volume  of  the  eye  appears  increased  in  some  inflammatory 
fevers,  and  particularly  in  cases  where  an  obstacle  exists  to  the  flow 
of  venous  blood  in  the  vessels  of  the  neck,  as  in  severe  anginose 
affections  and  apoplexy  by  strangulation ;  the  prominence  of  the 
eye  is  lessened,  on  the  contrary,  when  there  is  diminution  of  the 
cellular  substance  at  the  bottom  of  the  orbits.  The  unequal  sepa- 
ration of  the  eyelids  may  cause  an  apparent  difference  in  the 
prominence  of  the  two  eyes ;  but  in  all  these  cases  their  real  size 
remains  about  the  same.  The  size  of  this  organ  becomes  actually 
increased  in  internal  ophthalmia  and  hydrophthalmia  ;  it  is  dimin- 
ished in  the  atrophy  which  follows  various  diseases  of  this  organ, 
in  wounds  and  after  certain  operations.  It  becomes  very  promi- 
nent, without  increase  of  size,  when  a  tumor  is  developed  at  the 
bottom  of  the  orbit,  or  within  the  cranium,  which  presses  it  out 
(exophthalmid).  Inflammation  of  the  cellular  tissue  of  the  orbit 
produces  a  similar  effect.  The  color  of  the  eye  corresponds  with 
that  of  the  rest  of  the  face  ;  but  these  alterations  in  color  are  almost 
always  confined  to  the  sclerotic  and  its  covering  membrane,  the 
conjunctiva.  Dulness  of  the  cornea  is  not  unfrequently  observed 
in  acute  and  chronic  diseases  a  few  hours  before  death. 

The  cornea  sometimes  presents  spots  of  different  forms,  phlyc- 
taense,  liberations,  purulent  collections,  &c.,  in  the  diseases  wnich 
are  peculiar  to  it.  It  may  become  prominent,  the  effect  of  which 
is  to  increase  the  refraction  of  the  luminous  rays,  producing  what 
is  called  myopia ;  in  other  cases  it  becomes  flattened,  causing  a 
diminution  in  the  refracting  power  of  the  eye,  and  constituting 
presbyopia. 

The  motions  of  the  pupil  may  become  variously  deranged.  This 
aperture  is  sometimes  considerably  dilated,  although  exposed  to  a 
strong  light ;  or  it  may  contract  slightly  and  slowly,  as  in  coma- 


86  SYMPTOMS. 

tose  affections.  In  other  cases,  it  is  contracted,  as  in  internal 
ophthalmia  and  meningitis;  it  is  almost  always  immovable  in 
amaurosis,  and  sometimes  becomes  of  unequal  size  in  the  two 
eyes,  either  from  a  difference  in  their  natural  contractility,  or  from 
compression  of  one  side  of  the  brain;  its  form  becomes  irregular 
in  diseases  of  the  iris.  According  to  M.  Jadelot,  this  irregularity 
also  occurs  in  some  verminous  diseases. 

The  crystalline  with  its  capsule  become  opaque  in  cataract ;  the 
aqueous  and  vitreous  humors  become  changed  in  color  in  hypo- 
pyon  and  glaucoma. 

Professor  Sanson  has  recently  pointed  out  a  phenomenon,  which 
will  aid  in  the  diagnosis  of  many  diseases  of  the  eye.  If  a  light 
be  placed  before  this  organ,  no  part  of  which  has  been  rendered 
opaque  by  disease,  and  the  pupil  of  which  is  dilated  either  by 
the  action  of  belladonna  or  in  consequence  of  amaurosis,  three 
images  of  the  flame  will  be  distinctly  and  constantly  visible, 
situated  one  behind  the  other ;  of  these,  two  are  upright  and  the 
other  reversed.  The  most  anterior,  which  is  also  the  most  appa- 
rent, is  upright ;  that  situated  posteriorly,  is  the  palest  and  is  also 
upright;  the  third,  which  is  situated  between  the  other  two,  is 
reversed.  The  latter  is  the  smallest  of  the  three,  being  less  appa- 
rent than  the  anterior,  but  brighter  than  the  posterior,  image. 
These  three  images  fail  to  appear  if  the  cornea  be  opaque.  If  the 
opacity  affect  the  anterior  surface  of  the  capsule  only,  the  two 
posterior  images  are  not  visible ;  if  confined  to  its  posterior  surface, 
the  reversed  image  will  alone  be  wanting.  The  existence  of  the 
three  images  is  a  certain  sign  that  the  crystalline  and  its  capsule 
are  perfectly  transparent.  This  new  method  of  exploration  in 
diseases  of  the  eye,  enables  us  to  distinguish  with  certainty,  in 
some  obscure  cases,  between  amaurosis  and  black  cataract,  glau- 
coma and  the  ordinary  form  of  cataract.  * 

The  parts  comprised  by  Haller  in  the  term,  tutamina  oculi, 
present  in  disease  numerous  alterations. 

Rapid  and  repeated  motions  of  the  eyelids,  or  perpetual  nicta- 
tion (hippus)  is  observed  in  some  cases  of  mania  and  idiocy;  in 
other  cases,  as  in  adynamic  fevers,  their  motions  are  extremely 
slow,  and  occur  at  long  intervals.  In  cephalalgia  they  have  a 
feeling  of  weight,  as  some  patients  have  expressed  it ;  they  are  con- 
stantly closed  in  comatose  affections,  and  in  certain  cases  of 
ophthalmia  their  closure  is  accompanied  with  a  violent  contraction 
of  the  muscles ;  they  remain  partially  open  during  sleep,  in  some 
persons ;  in  others,  during  the  waking  state,  they  are  unequally 
separated  on  the  two  sides,  as  is  sometimes  observed  in  hemicrania, 
hemiplegia,  and  certain  acute  cerebral  diseases.  In  partial  paraly- 
sis, produced  by  a  lesion  of  the  nerve  of  the  seventh  pair,  closure 

*  L"1  Experience,  No.  1,  1837,  t.  1,  p.  1,  M.  M.  Bardinot  et  Pigne,  pupils  of 
Sanson,  have  shown  by  a  series  of  careful  experiments  performed  in  the  presence 
of  the  professor,  that  the  anterior  image  is  produced  by  the  cornea,  the  middle 
one  is  reflected  by  the  posterior  segment  of  the  capsule,  and  the  posterior  one 
by  its  anterior  segment. 


SYMPTOMS.  87 

of  the  eyelids  is  impossible,  in  consequence  of  a  partial  loss  of 
contractility  of  the  orbicularis  muscle.  The  volume  of  the  eyelids 
with  that  of  the  neighboring  parts,  becomes  increased  in  erysipelas 
of  the  face  and  in  oedema ;  the  swelling  of  this  part  is  generally 
more  considerable  on  account  of  the  laxity  of  the  cellular  tissue,  of 
which  its  structure  is  composed ;  they  sometimes  become  suddenly 
emphysematous,  from  contusion  at  the  root  of  the  nose,  or  after 
violent  efforts  to  blow  the  nose.  In  both  cases  it  is  owing  to  a 
rupture  of  the  osseous  parts  which  form  the  roof  of  the  nose.  The 
color  of  the  eyelids  generally  corresponds  to  that  of  the  face.  Their 
free  edges  become  red  and  swollen  in  chronic  ophthalmia;  they 
become  inverted  and  everted  in  some  diseases  of  which  they  are 
the  seat.  Their  adherent  borders,  particularly  of  the  lower  lid,  are 
often  marked  by  a  bluish  line :  the  eyes  are  then  said  to  be  cernes. 
This  phenomenon  occurs  in  many  females  during  menstruation. 
It  may  however  be  produced  in  both  sexes  by  watchfulness,  fa- 
tigue, excessive  coitus,  and  excessive  evacuations  of  any  kind. 

The  conjunctiva  becomes  more  moist  and  of  a  deeper  red  in  erup- 
tive fevers,  typhus,  and  particularly  in  ophthalmia.  It  is  more 
or  less  swollen  in  inflammation,  and  often  forms  a  sort  of  border 
around  the  cornea  (chemosis).  Its  natural  humidity  becomes  some- 
times diminished  :  the  eyes  are  then  said  to  be  dry.  In  some  cases 
the  mucus  which  it  exhales,  forms  whitish  striae  on  the  globe  of 
the  eye ;  in  grave  diseases  the  patient  becomes  unconscious,  and 
neglects  to  clear  it  away. 

The  caruncula  lachrymalis  furnishes  few  important  symptoms  ; 
it  is  of  a  bright  red  color  in  inflammatory  diseases,  and  becomes 
pale  in  chronic  affections.  Paleness  of  this  little  organ  is  by  some 
authors  considered  as  a  never  failing  symptom  in  dropsy ;  but  this 
is  incorrect.  Hairs  are  sometimes  developed  on  its  surface,  which 
by  contact  irritate  the  eye,  and  produce  obstinate  ophthalmia. 

The  eyelashes  become  sometimes  covered  with  dust,  and  more 
often  with  scales,  in  affections  of  the  eye  and  in  severe  acute  dis- 
eases. Their  inversion  produces  obstinate  ophthalmia,  and  their 
fall  is  often  the  result  of  ulceration  of  the  free  edges  of  the  eyelids. 
Their  length  when  considerable  has,  by  some  physicians,  been 
thought  to  belong  to  the  tubercular  constitution. 

The  lachrymal  sac  becomes  swollen,  red  and  ulcerated,  when 
any  obstacle  exists  to  the  passage  of  the  tears  into  the  nasal  canal. 
A  flowing  of  the  tears  over  the  cheek  is  often  produced  by  the 
same  cause.  This  latter  symptom,  called  epiphora,  may  also  be 
owing  to  closure  of  the  puncta  and  lachrymal  canals,  and  also  to 
paralysis  of  the  lids  or  eversion  of  the  lower  lid. 

The  eyebrows  are  raised  in  the  furious  delirium  of  fevers  and 
paroxysms  of  mania,  and  depressed  in  cases  of  melancholy  and 
violent  cephalalgia.  They  are  alternately  elevated  and  depressed 
during  inspiration  and  expiration,  in  certain  diseases  accompanied 
with  great  difficulty  of  breathing.  These  alternate  movements 
are  sometimes  confined  to  one  brow,  the  other  remaining  immov- 
able. In  paralysis  of  the  facial  nerve,  the  eyebrow  of  the  same 


88  SYMPTOMS. 

side  is  depressed,  and  can  no  longer  be  drawn  towards  that  of  the 
opposite  side. 

The  forehead  in  health  is  ordinarily  smooth  and  serene.  It  be- 
comes wrinkled  in  painful  and  convulsive,  and  is  the  seat  of  a 
papular  eruption  and  exostosis  in  syphilitic,  aifections. 

The  temples  in  their  natural  state  are  full  and  smooth ;  they 
become  concave  towards  the  termination  of  acute  and  chronic  dis- 
eases. The  pulsations  of  the  superficial  arteries  of  this  region  are 
more  manifest  in  diseases  attended  with  an  increased  flow  of  blood 
to  the  head. 

The  cheeks,  firm  and  round  in  health,  and  exhibiting  more  color 
in  the  malar  regions,  may  become  in  disease  agitated  with  convul- 
sive motions,  or  paralyzed ;  in  the  latter  case,  they  are  flabby  and 
become  distended  with  food  in  mastication,  and  with  air  if  the 
patient  attempt  to  blow  out  a  light.  One  or  both  cheeks  may  be 
increased  in  bulk  in  odontalgia  and  certain  affections  of  the  max- 
illary sinus.  They  sometimes  become  the  seat  of  red  and  obstinate 
pustules  known  by  the  name  of  guff  a  rosea,  which  some  physi- 
cians have  supposed  to  be  connected  with  a  peculiar  affection  of 
the  liver. 

The  nose,  which  contributes  but  little  to  the  expression  of  the 
face,  furnishes  few  symptoms.  It  has  been  sometimes  observed  to 
deviate  to  the  right  or  left  before  a  convulsive  attack,  and  to 
become  red  before  epistaxis.  It  is  swollen  and  shining  at  the  com- 
mencement of  erysipelas  which  has  not  yet  extended  to  the  rest  of 
the  face.  It  becomes  thin  towards  the  close  of  acute  and  chronic 
diseases.  Its  extremity  becomes  livid  and  gangrenous  in  certain 
adynamic  fevers,  or  in  consequence  of  severe  cold. 

The  nares  also  deserve  attention ;  their  dilation  is  rapid  and 
convulsive  at  the  moment  of  respiration  in  affections  accompanied 
with  considerable  difficulty  of  breathing ;  but  in  cases  of  extreme 
debility  and  emaciation  they  are  contracted,  as  is  observed  in  the 
hippocratic  countenance.  In  paralysis  of  the  facial  nerve  the  naris 
of  the  affected  side  is  immovable  ;  and  not  only  is  it  incapable  of 
dilatation  during  the  act  of  inspiration,  but  is  often  depressed.  The 
nares  are  sometimes  filled  with  a  blackish  mucus  in  the  course 
of  grave  fevers  ;  they  become  the  seat  of  a  scaly  eruption  towards 
the  close  of  some  light  diseases,  and  of  fissures  in  scrofulous  chil- 
dren. Tumors  developed  in  the  nasal  fossas  may  be  seen  in  the 
interior  of  the  nares,  and  in  some  cases  they  protrude  beyond  these 
openings. 

The  lips  in  healthy  persons  are  free  and  supple  in  their  motions  ; 
when  at  rest,  they  are  closed,  firm  and  sustained  by  the  action  of 
their  muscles ;  their  borders  are  smooth,  rounded,  and  of  a  rose 
color.  In  disease,  they  present  important  alterations  in  respect  to 
their  position,  motions,  volume,  color,  state  of  dryness  or  humidity, 
and  the  eruptions  of  which  they  are  the  seat. 

They  are  pendent  in  adynamic  fevers,  and  in  the  agony  of  vari- 
ous diseases  ;  they  are  widely  separated  from  each  other  in  forward 
dislocation  of  the  lower  jaw ;  compressed  and  contracted  in  violent 


SYMPTOMS.  89 

pain ;  trembling,  in  some  nervous  affections :  they  are  suddenly 
thrust  forward  and  separated  at  each  expiration  in  certain  cerebral 
affections ;  this  is  said  to  resemble  a  person  in  the  act  of  smoking  a 
pipe.  The  lips  are  drawn  to  the  right  or  left,  when  one  side  of 
the  face  is  affected  with  paralysis,  or  convulsion ;  in  the  latter 
case  the  symptom  is  called  a  cynic  spasm  (spasmus  cynicus);  * 
when  the  two  commissures  are  drawn  away  from  each  other,  it  is 
called  the  risus  sardonicus.-\  It  has  been  said  that  the  upper  lip 
is  thick  in  scrofulous  persons,  but  to  this  there  are  numerous  ex- 
ceptions. Swelling  of  both  lips  precedes  and  accompanies  the 
eruptions  which  sometimes  appear  at  the  decline  of  certain  acute 
affections. 

Their  color  is  of  a  vermilion  red  in  inflammatory  diseases,  pale 
in  anemia  and  chlorosis,  livid  in  the  cold  stage  of  intermittent  fevers 
and  in  organic  lesions  of  the  heart. 

The  lips  are  dry,  ordinarily  smooth,  sometimes  cracked,  in  grave 
fevers ;  they  may  also  become  covered  with  a  dry  and  blackish 
coat,  similar  to  that  which  appears  upon  the  teeth  and  tongue. 
This  dryness  and  these  deposits  of  buccal  mucus  are  sometimes 
observed  in  the  lightest  affections,  and  even  in  healthy  persons  who 
sleep  with  the  mouth  open.  The  necessity  of  sleeping  with  the 
mouth  open  is  connected  with  an  anatomical  disposition  which  we 
do  not  recollect  to  have  seen  pointed  out.  It  consists  in  a  malfor- 
mation of  the  roof  of  the  mouth,  which  being  too  much  arched 
towards  the  nasal  fossae  and  too  narrow  between  the  dental  arches, 
produces,  as  the  inevitable  result,  narrowness  and  shortness  of 
the  nasal  fossae,  or  rather  a  drawing  up  of  the  upper  lip.  All 
those  persons,  in  whom  the  upper  lip  does  not  cover  the  teeth, 
not  extending  below  the  alveoli,  sleep  necessarily  with  the  mouth 
open. 

The  chin  participates  in  the  changes  which  the  face  undergoes  ; 
there  are  few  which  are  peculiar  to  it.  It  deviates  from  the 
median  line  of  the  body  in  dislocation  of  one  side  of  the  jaw,  and  is 
often  deformed  in  fracture  of  this  bone.  It  sometimes  becomes  the 
seat  of  an  herpetic  eruption,  known  by  the  name  mentagra.  It 
presents  in  the  agony,  at  the  moment  of  the  last  inspiration,  a  con- 
vulsive falling  which  immediately  precedes  death. 

The  parotid  regions  become,  in  some  affections,  the  seat  of  a 
remarkable  swelling,  affecting  the  glands  themselves  or  the  cellu- 
lar substance  in  which  they  are  enveloped.  This  swelling,  which 
occurs  in  typhus  and  many  other  acute  diseases,  either  at  their 
commencement  or  termination,  demands  the  careful  attention  of  the 
physician.  To  this  symptom  the  term  parotis  has  been  applied. 
It  may  be  confined  to  both  sides,  or  extend  to  both  at  once,  or  suc- 
cessively ;  it  may  be  hardly  perceptible  or  very  considerable,  &c. 

*    JCvtav,  xfroc,  a  dog. 

f  It  has  been  said  that  this  name  was  given  to  the  convulsive  laugh,  from  its 
having  been  sometimes  produced  by  the  use  of  a  plant  [ranunculus]  which  grows 
in  Sardinia,  ab  herba  Sardonia. 

8* 


90  SYMPTOMS. 

The  ears  are  livid  and  cold  during  the  first  stage  of  intermittent 
fevers ;  red  and  burning  in  the  paroxysm  of  nearly  all  febrile 
affections,  and  particularly  those  accompanied  with  a  determination 
of  blood  to  the  head.  The  meatus  externus  may  become  the  seat 
of  various  discharges,  as  mucus,  pus,  blood,  and  in  some  cases  frag- 
ments of  bone.  In  some  affections,  the  air  which  penetrates  into 
the  cavity  of  the  tympanum  through  the  eustachian  tube,  may 
issue  from  the  meatus  with  sufficient  force  to  agitate  a  light  placed 
before  it,  or  to  produce  a  gurgling  sound  as  it  mixes  with  the  pus 
which  may  be  contained  in  the  part.  This  canal  may  be  con- 
tracted, or  obliterated  by  vegetations  or  polypi,  tumefaction  of  its 
lining  membrane,  the  accumulation  and  desiccation  of  the  matters 
it  secretes,  pressure  exerted  upon  it  by  an  abscess  formed  in  its 
substance,  or  tumor  developed  near  it.  The  mastoid  process  may 
become  unusually  prominent  in  consequence  of  disease  of  the  bone ; 
atrophy  of  this  bone  has  been  sometimes  noticed,  following  caries. 

The  loss  of  the  hair,  which  Hippocrates  supposed  to  be  a  symp- 
tom of  phthisis,  rarely  accompanies  this  disease.  It  is  of  frequent 
occurrence  in  syphilitic  affections,  affecting  the  beard  and  other  por- 
tions of  the  pilous  system ;  the  hair  is  after  a  certain  time  partially 
restored.  Where  this  is  not  the  case,  the  phenomenon  is  desig- 
nated by  the  term  alopecia,*  a  rare  symptom,  the  causes  of  which 
are  unknown.  The  fall  of  hair  is  not  unfrequently  noticed  during 
convalescence  from  typhus  and  eruptive  fevers.  The  hair  turns 
white  in  some  instances,  under  the  influence  of  a  severe  moral 
shock.  It  becomes  of  a  greenish  hue  in  those  who  work  in  copper, 
and  red  in  those  employed  in  the  preparation  of  minium. 

In  tinea,  the  hair  falls  off,  and  is  replaced  by  wooly  tufts  scat- 
tered over  the  scalp.  In  plica  polonica,  the  inextricable  interlacing 
of  the  hair  is  the  principal  symptom  of  this  singular  disease. 

The  neck  becomes  increased  in  bulk  in  some  anginose  affections, 
and  in  goitre ;  it  is  diminished  in  size,  with  other  parts,  in  general 
emaciation,  when  it  appears  lengthened.  The  distension  of  the 
superficial  veins  of  the  neck  and  external  jugulars,  the  undulatory 
reflux  of  the  blood  in  these  vessels,  from  the  clavicle  where  it  is 
very  apparent,  to  the  neighborhood  of  the  jaw  where  it  is  no 
longer  perceptible,  has  been  pointed  out  as  alone  existing  in  aneu- 
rism of  the  right  cavities  of  the  heart ;  but  more  accurate  obser- 
vations have  shown  that  it  occurs  as  well  in  affections  of  the  left 
as  right  side  of  the  heart,  and  particularly  in  contraction  of  its 
orifices.  Pulsations  of  the  carotids  are  frequently  observed  in 
active  aneurism  of  the  left  ventricle  ;  this  symptom  also  sometimes 
precedes  delirium  in  acute  diseases.  Enlargement  of  the  lymphatic 
glands  is  one  of  the  most  important  symptoms  presented  by  the  cer- 
vical region.  It  accompanies  or  precedes  acute  and  chronic 
eruptions  of  the  face  and  scalp.  Sudden  swelling  of  the  glands, 
accompanied  by  febrile  symptoms,  is  an  almost  certain  sign  of  ap- 

*  Alunrfe,  a  fox.  This  animal  is  said  to  be  subject,  in  old  age.  to  the  loss  of 
its  hair. 


SYMPTOMS.  91 

preaching  erysipelas  of  the  face.     That  which  comes  on  slowly  is 
often  owing  to  an  affection  of  one  of  the  neighboring  teeth. 

The  chest,  which  in  the  healthy  man  is  of  a  size  proportionate  to 
his  stature  and  strength,  is  narrow  and  flat  in  pulmonary  phthisis, 
and  prominent  in  pulmonary  emphysema.  In  rachitis,  it  presents 
various  and  numerous  malformations  to  which  we  can  here  but 
allude,  as  they  belong  rather  to  the  history  of  that  disease,  than  to 
general  pathology.  The  integuments  covering  the  chest  become 
very  thin  in  chronic  diseases ;  in  the  last  stages  of  phthisis  they 
form  over  the  whole,  or  but  a  part  of  its  extent,  deep  depressions 
between  the  ribs.  In  empyema,  on  the  contrary,  the  intercostal 
spaces  are  often  more  prominent  than  the  ribs  themselves ;  this  pe- 
culiar disposition  is  only  perceptible  where  the  integuments  are  very 
thin.  There  are  certain  cases  in  which  one  side  of  the  chest  is  more 
voluminous  than  the  other;  this  morbid  disposition  may  depend  on 
one  of  two  opposite  causes,  either  enlargement  of  one,  or  contraction 
of  the  other  side;  so  that  the  disease  is  sometimes  seated  in  the 
larger,  and  sometimes  in  the  smaller  side.  Enlargement  is  owing 
to  dilatation  of  the  pulmonary  vesicles,  or  an  accumulation  of  fluid, 
and  sometimes  of  air,  in  the  cavity  of  the  pleura.  Contraction 
always  follows  effusion,  and  consequently  enlargement  of  the  same 
side  of  the  chest :  the  lung  which  has  been  for  a  time  compressed, 
regains  its  dimensions,  if  at  all,  very  slowly,  and  its  parietes  in  ac- 
commodating themselves  to  it,  lose  part  of  their  fulness.  A  more 
circumscribed  portion  of  the  chest  may  present  a  fulness  or  partial 
depression  :  the  former  is  sometimes  observed,  though  often  with 
difficulty,  in  pleuritic  effusion  confined  to  the  base  of  one  side  of 
the  chest,  and  more  manifestly,  in  cases  of  arterial  aneurism  de- 
veloped under  the  sternum  or  ribs,  in  pericarditis  with  effusion,  in 
hypertrophy  of  the  heart  and  in  some  cases  of  pulmonary  emphy- 
sema. But  to  avoid  error,  it  should  be  recollected  that,  according 
to  the  researches  of  M.  Woillez,*  the  right  side  of  the  chest  is 
normally  larger  than  the  left,  the  difference  varying  from  one  half 
a  centimetre  to  three  centimetres  [about  one  inch] ;  that  in  left- 
handed  persons  there  is  often  observed  a  prominence  upon  the  left 
side  anteriorly,  which  seems  to  depend  upon  increased  thickness 
of  the  soft  parts  ;  that  there  are  also  persons  whose  chests  are  nat- 
urally prominent  on  one  side,  while  they  are  depressed  upon  the 
other.  The  disposition  is  the  reverse,  in  such  cases,  upon  the 
opposite  side.  Partial  contraction  is  particularly  observable  beneath 
the  clavicles,  in  certain  forms  of  tubercular  phthisis,  and  more 
rarely  at  the  base  of  the  thorax,  after  the  absorption  of  pleuritic 
effusions  confined  to  that  region. 

The  mammae,  furnish  certain  symptoms  which  will  be  consid- 
ered elsewhere. 

The  shoulders  are  raised  and  prominent  in  phthisical  patients; 
one  is  lower  than  the  other  in  lateral  curvature  of  the  trunk, 
pointed  out  by  Laennec  in  those  suffering  or  convalescent  from 

*  Recherches  sur  I'insp.  et  la  mensur.  de  la  poitrine.     8vo.  Paris,  1838. 


92  SYMPTOMS. 

considerable  and  prolonged  pleuritic  effusion.  Prominence  of  one 
of  the  dorsal  vertebrae  is  the  most  important  symptom  in  Potts' 
disease.  In  spina  bifida,  a  soft,  fluctuating,  and  often  translucent 
tumor  in  the  vertebral  region  is  distinguishable  by  the  eye,  and 
the  absence  of  one  or  more  spinous  processes  can  be  felt.  A  depres- 
sion at  the  lower  extremity  of  the  sternum,  in  some  workmen,  is 
rather  owing  to  habitual  pressure  on  the  part  by  the  instruments 
they  employ,  than  to  disease.  This  is  most  frequently  observed  in 
shoemakers. 

The  exploration  of  the  chest,  by  means  of  percussion  and 
auscultation,  reveals  many  other  very  important  phenomena,  which 
will  be  considered  in  the  articles  on  the  symptoms  furnished  by  the 
respiration  and  circulation,  and  in  the  chapter  on  diagnosis. 

The  abdomen,  in  health,  varies  in  size  in  different  individuals, 
and  is  moderately  resonant;  it  is  firm  without  hardness,  and 
pliant  without  softness. 

The  skin  of  the  abdomen  is  generally  smooth  and  of  a  white  color. 
In  women  who  have  been  once  pregnant,  and  particularly  those 
who  have  borne  many  children,  whitish  or  bluish  wrinkles  are  ob- 
served extending  across  the  hypogastric  region,  to  which  the  term 
vergetures  has  been  applied,  and  which  are  certain  indices  of  pre- 
vious pregnancy  ;  but  it  should  be  recollected  that  this  sign  fails  in 
some  women  who  have  borne  children,  and  sometimes  occurs  in 
persons  of  both  sexes,  in  whom  distension  of  the  abdomen  has 
previously  taken  place,  either  from  a  considerable  accumulation  of 
serum  or  fat.  It  is  chiefly  upon  the  surface  of  the  abdomen  that 
the  rose-colored  lenticular  spots,  peculiar  to  typhoid  and  typhus 
fevers,  appear.  The  subcutaneous  veins,  in  some  cases  of  ascites, 
become  considerably  enlarged,  forming  a  true  varicose  network, 
which  will  be  hereafter  considered  (venous  circulation).  There 
often  exists  in  pregnant  women,  on  the  median  line,  extending 
from  the  umbilicus  to  the  pubis,  a  brownish  coloration,  owing  to  a 
superabundant  secretion  of  pigmentum.  The  lower  half  of  the 
linea  alba  sometimes  presents  below  the  umbilicus  a  very  narrow 
opening,  not  easily  distinguished,  in  which  a  small  portion  of  the 
epiploon  may  become  engaged.  This  affection  has  often  given  rise 
to  obstinate  vomiting  and  considerable  emaciation,  which  has  led 
to  the  belief  in  the  existence  of  stomachal  cancer,  and  which  has 
been  cured  by  the  application  of  a  bandage.  It  is  therefore  of  the 
greatest  importance  in  patients  attacked  with  vomiting,  to  exam- 
ine with  particular  care  the  whole  extent  of  the  linea  alba,  as  well 
as  all  other  parts  of  the  abdominal  surface  where  hernia  is  liable 
to  occur.  Lastly,  after  repeated  parturition,  the  linea  alba  some- 
times becomes  thin  and  ruptured,  allowing  the  intestines  to  form 
considerable  tumors;  and  in  subsequent  pregnancies,  the  womb 
has  been  known  to  fall  forward  in  front  of  the  pubis,  forming  an 
enormous  protuberance. 

The  volume  of  the  abdomen  may  be  increased  or  diminished 
under  the  influence  of  disease;  its  increase  may  be  partial  or 
general.  In  the  latter  case,  it  is  almost  always  owing  to  the 


SYMPTOMS.  93 

presence  of  gas  in  the  digestive  canal,  some  fluid  in  the  cavity 
of  the  peritoneum,  or  an  abundant  exhalation  of  fat  within  the 
cavity,  and  in  the  parietes  of  the  abdomen.  A  moderate  accumu- 
lation of  air  in  the  intestines  increases  the  bulk  and  resonance  of 
the  abdomen  :  this  is  termed  meteorism  (meteorismus).*  If  the 
accumulation  be  more  abundant  with  distension  of  the  abdomen, 
it  is  called  tympanites  ;f  these  two  words  express  nearly  the  same 
thing :  the  latter  is,  however,  more  generally  employed  in  chronic 
diseases,  and  the  former  in  acute  affections,  and  particularly  grave 
fevers.  J 

The  abdomen  is  frequently  the  seat  of  partial  swellings.  These 
occur  in  the  hypochondriac  regions  in  diseases  of  the  liver  and 
spleen,  and  in  the  epigastrium  in  hysteria.  The  bladder  when 
distended  with  urine,  forms  an  ovoid  tumor  in  the  hypogastrium, 
which  sometimes  extends  to  the  umbilicus;  the  intestines,  stomach, 
uterus,  ovaries,  and  mesentric  glands,  may  also  form,  in  the  dif- 
ferent regions  of  the  abdomen,  tumors  more  or  less  distinct  to 
the  touch  and  sometimes  to  the  eye :  so  with  the  cysts  which  are 
occasionally  developed  within  this  cavity,  &c.  These  various  tu- 
mors are,  in  some  cases,  very  apparent,  in  others,  they  are  alone 
evident  from  an  obscure  and  deep  seated  resistance  which  they 
present. 

Diminution  in  the  volume  of  the  abdomen  may  be  general  or 
partial. 

Its  volume  is  diminished  in  many  chronic  diseases,  in  conse- 
quence of  the  general  emaciation.  It  becomes  suddenly  dimin- 
ished also  in  some  acute  affections,  as  in  violent  colic,  and  par- 
ticularly that  produced  by  lead.  In  adynamic  fevers  and  perito- 
nitis, the  abdomen  often  falls  away  a  short  time  before  death :  a 
similar  phenomenon  is  sometimes  observed  in  patients  who  die 
dropsical.  The  abdomen  becomes  alternately  diminished  and 
increased  in  size  in  some  affections,  and  particularly  in  hysteria 
and  schirrus  of  the  large  intestines.  The  most  important  sign  of 
the  latter  affection  is  prolonged  constipation  with  progressive 
enlargement  of  the  abdomen,  alternating  with  abundant  stools, 
which  are  followed  by  immediate  sinking  of  the  abdominal  pari- 
etes. In  hysteria,  on  the  contrary,  enlargement  of  the  abdomen 
comes  on  rapidly,  in  consequence  of  gaseous  exhalation,  often 
disappearing  as  rapidly,  without  the  appearance  of  any  evacua- 
tion. Partial  diminution  of  the  abdomen  is  more  rarely  observed 
than  circumscribed  swelling:  it  is  relative  rather  than  absolute, 
and  commonly  succeeds  the  latter :  such  is  that  observed  in  the 
epigastrium,  in  some  nervous  affections,  in  the  hypogastrium  after 
the  excretion  of  urine  which  has  been  for  a  long  time  retained  in 
the  hypochondriac  regions,  on  a  favorable  termination  of  engorge- 
ment of  the  liver  or  spleen,  &c.  A  partial  diminution  may,  how- 
ever, take  place  in  some  very  rare  cases ;  as  depression  ot  the 


,  from  utTEwQog,  elevated. 
,  a  drum. 
FRANCE.,  t.  vii.,  p.  55. 


94  SYMPTOMS. 

epigastrium  and  left  side  from  displacement  of  the  spleen  or 
stomach.  Many  examples  of  this  are  cited  by  Morgagni.  M. 
Rayer  has  recently  shown  that  displacement  of  a  kidney  may  also 
give  rise  to  these  phenomena.  In  a  case,  in  which  the  kidneys 
appeared  placed  transversely  across  the  vertebral  column,  the  lum- 
bar region  was  depressed  and  flattened  like  the  two  sides  of  a 
saddle.*  It  is  necessary,  in  order  to  distinguish  this  appearance, 
that  the  patient  be  placed  on  all  fours. 

The  form  of  the  abdomen  is  generally  in  relation  to  its 
volume;  both  increasing  and  diminishing  simultaneously.  The 
abdomen  may,  however,  become  very  hard,  although  diminished 
in  volume,  as  in  metallic  colic.  An  unusual  resistance  felt  over 
the  whole  region  is,  in  some  cases,  the  only  symptom  of  chronic 
peritonitis.  The  abdomen  is  soft  in  some  cases  of  dropsy,  when 
the  quantity  of  fluid  has  been  lessened  by  absorption  or  punc- 
ture. 

The  form  of  the  abdomen  varies  according  to  the  disease  that 
produces  its  increase ;  in  ascites,  its  dilatation  takes  place  particu- 
larly from  before  backward,  and  the  umbilicus,  raised  by  the  fluid 
that  distends  it,  sometimes  forms  a  small,  pellucid  tumor,  which 
rests  upon  the  enormous  swelling  presented  by  the  abdomen.  In 
03dematous  swelling  of  the  abdominal  parietes,  on  the  contrary, 
the  transverse  diameter  is  the  greatest,  and  the  flanks  acquire  an 
extraordinary  width.  In  both  cases  the  abdomen,  to  use  the 
vulgar  expression,  falls  to  that  side  on  which  the  patient  lies ;  its 
form,  in  other  respects,  is  regular.  It  is  otherwise  in  the  cases  in 
which  the  increased  size  is  owing  to  an  encysted  tumor,  or  to  an 
organic  affection  of  any  viscus :  in  such  cases,  unless  there  be 
accompanying  ascites,  the  abdomen  presents  a  remarkable  irregu- 
larity of  form,  particularly  in  the  first  stage  of  the  disease. 

The  abdomen  presents  at  various  points,  and  particularly  at  the 
umbilicus,  inguinal  ring,  crural  arch,  and  on  a  level  with  the 
obturator  foramina,  tumors  which  appear  and  disappear,  or  at  least 
become  increased  and  diminished  under  certain  circumstances, 
and  which  are  formed  of  some  one  of  the  parts  naturally  contained 
within  the  cavity  of  the  abdomen,  protruding  through  one  of 
the  apertures  alluded  to.  These  tumors,  which  are  called  hernice, 
may  occur  in  the  thorax  and  head ;  but  they  are  as  rare  in  those 
parts,  as  they  are  common  in  the  abdomen.  The  inguinal  regions 
are  also  the  seat  of  many  important  phenomena,  such  as  the 
buboes  which  occur  in  syphilis  and  the  plague.  The  abscesses 
formed  in  the  iliac  regions  and  in  front  of  the  vertebral  column, 
make  their  appearance  in  these  regions. 

The  organs  of  generation  furnish  several  important  phenom- 
ena :  the  primary  symptoms  of  syphilis  almost  always  occur  in 
these  parts,  and  it  is  here  that  discharges,  ulcers,  vegetations  fre- 
quently manifest  themselves. 

The  penis  is  increased  beyond  its  natural  size  in  children  af- 

*  RAYER.     Malad.  des  Reins.  Obs.  xxxiii.,  t.  1,  p.  407. 


SYMPTOMS.  95 

fected  with  stone,  in  those  addicted  to  masturbation,  and  in  adults 
who  have  indulged  immoderately  in  the  pleasures  of  love.  It  is, 
in  most  diseases,  in  a  state  of  permanent  flaccidity ;  it  disappears 
beneath  the  integuments  in  some  affections  of  the  scrotum  and 
tunica  vaginalis.  In  other  diseases,  as  blenorrhagia  and  satyriasis, 
it  is,  on  the  contrary,  continually  in  a  state  of  erection.  The 
testicles  are  retracted  strongly  against  the  inguinal  ring  in  cases  of 
nephritic  calculus,  ilio-scrotal  neuralgia,  and  violent  colic;  this 
retraction  is,  in  some  cases,  attended  with  very  severe  local  pain. 
The  epidydimis  and  spermatic  cord  are  the  common  seat  of  the 
inflammation  which  is  said  to  be  the  consequence  of  repelled  go- 
norrhoea, and  which  was  for  a  long  time  supposed  to  be  an  affection 
of  the  testicle  itself,  which  is  but  rarely  and  secondarily  affected. 
The  tunica  vaginalis,  distended  with  the  fluid  it  exhales,  is  the 
ordinary  seat  of  hydrocele  which  sometimes  also  affects  the  sper- 
matic cord.  The  scrotum  is  considerably  swollen  in  anasarca, 
voluminous  inguinal  hernise,  urinal  abscesses,  &c. 

The  labia  'major a,  in  the  female,  often  become  enormously^  swol- 
len in  dropsy ;  they  are  sometimes,  as  are  the  testicles  in  the  male, 
the  seat  of  violent  inflammation,  succeeding  and  alternating  with 
parotiditis.  The  vulva  is  the  seat  of  ulcerations  and  vegetations 
of  a  syphilitic  origin,  and  not  unfrequently  of  lypomatous  and 
steatomatous  tumors.  The  labia  majora  may  also,  together  with 
the  clitoris,  become  hypertrophied ;  the  various  malformations 
which  characterize  the  female  hermaphrodite  and  the  tumors  which 
take  their  rise  in  the  uterus,  here  make  their  appearance.  Lastly, 
there  is  sometimes  observed,  during  pregnancy,  a  varicose  develop- 
ment of  veins,  which  is  often  but  precursory  to  a  much  more 
serious  disease,  the  trombus  or  sanguineous  tumor,  an  affection 
which  is  peculiar  to  the  period  of  labor. 

The  limbs  also  furnish  to  symptomatology  numerous  phenomena. 

They  are  immovable  and  pliant  in  paralysis ;  their  immobility 
is  accompanied  with  stiffness,  in  softening  of  the  brain,  in  various 
organic  diseases  of  this  viscus,  in  rheumatic  affections,  cramps  and 
tonic  convulsions ;  their  movements  are  disordered  in  some  nervous 
affections,  as  chorea  and  hysteria. 

They  become  increased  and  diminished  in  size  in  those  diseases 
which  produce  like  effects  in  other  parts  of  the  body. 

One  of  the  limbs  may  become  cedematous  and  engorged,  when 
the  vessels  and  nerves  which  are  distributed  to  it,  are  compressed 
by  a  tumor.  A  tumor  in  the  side  may  produce  these  results  in  the 
corresponding  thigh ;  the  arm  is  similarly  affected  in  aneurism  of 
the  arch  of  the  aorta.  These  phenomena  principally  depend  upon 
some  obstruction  to  the  venous  circulation,  which  may  also  produce 
a  varicose  development  of  the  superficial  veins. 

The  limbs  often  become  swollen  around  the  articulations,  or  in 
the  parts  between;  the  first  takes  place  in  articular  rheumatism,  hy- 
darthrosis,  white  swelling,  &c. ;  the  second,  which  is  much  more 
rare,  sometimes  occurs  in  scurvy,  in  which  the  muscles  become  the 
seat  of  a  sanguineous  exhalation  between  their  fibres ;  phlegmon, 


96  SYMPTOMS. 

abscesses  and  aneurisms  may  also  produce  partial  swellings   in 
these  as  in  other  parts  of  the  body. 

The  limbs  become  diminished  in  size,  in  paralysis;  in  such 
cases  the  paralyzed  limbs  are  those  affected,  in  paraplegia  both 
thighs,  in  hemiplegia  the  leg  and  arm  of  one  side.  In  the  paralysis, 
which  occurs  in  children,  increase  in  the  length  of  the  limb  is 
sometimes  checked,  the  part  remaining  for  several  years  shorter 
by  some  inches  than  the  other,  and  smaller  in  other  respects. 
This  atrophy  is  often  observed  to  follow  spontaneous  dislocations. 

The  extremities  of  the  limbs  also  present  remarkable  changes, 
in  respect  to  size.  Without  noticing  the  diseases  of  which  they 
are  the  special  seat,  as  gout  and  caries,  the  hands  are  swollen  in 
scarlatina  and  variola  ;  it  has  also  been  remarked,  that  in  plethora, 
the  general  intumescence  is  much  more  apparent  in  the  hands 
than  elsewhere ;  the  fingers  are  sometimes  so  much  swollen  as  to 
be  with  difficulty  flexed.  Beclard  having  observed  that,  in  many 
children  affected  with  cardiac  aneurism,  the  last  phalanx  of  the 
fingers  was  so  much  enlarged  as  to  give  the  finger  the  form  of  a 
small  club,  was  led  to  believe  that  a  connection  existed  between 
this  peculiarity  and  lesions  of  the  heart,  and  considered  it  a  sign 
of  those  diseases.  This  form  of  the  fingers  has  been  more  recently 
thought  to  be  peculiar  to  tubercular  disease  of  the  lungs.  This 
phenomenon  does  not  appear  to  us,  in  a  semeiotic  point  of  view, 
to  deserve  the  importance  that  has  been  attached  to  it. 

The  feet  become  swollen  in  some  affections,  and  particularly  in 
incipient  anasarca. 

The  alterations  in  color  presented  by  the  skin,  are,  in  some  af- 
fections, more  marked  at  the  extremities  than  in  other  parts  of  the 
limbs  and  trunk ;  as  the  lividity  which  occurs  in  the  cold  stage  of 
febrile  affections,  the  marbled  appearance  observed  in  some  ady- 
namic  fevers,  and  the  bluish  tint  which  occurs  in  Asiatic  cholera, 
in  diseases  of  the  heart,  and  in  all  cases  where  there  is  any  ob- 
struction to  the  pulmonary  or  cardiac  circulation.  We  have  seen 
the  feet  of  a  woman  affected  with  elephantiasis,  of  a  greyish  slate 
color,  with  deep  and  regular  furrows,  and  a  hard  and  swollen  con- 
dition of  their  tissue. 

The  nails  deserve  little  attention,  in  relation  to  symptomatology ; 
they  are  pale  or  livid  in  the  cold  stage  of  intermittent  fevers,  and 
present  a  yellowish  tint  in  icterus.  Hippocrates  observed  that 
they  were  curved  in  phthisical  patients  :  this  phenomenon,  what- 
ever be  its  cause,  is  here  rarely  well  marked. 

Such  are  the  principal  symptoms  furnished  by  the  exterior  of 
the  body ;  there  are  many  others  which  we  have  not  considered, 
as  their  place  is  more  naturally  among  those  furnished  by  each 
particular  function. 


SYMPTOMS.  97 

SECTION   SECOND. 
Symptoms  furnished  by  the  Organs  of  Locomotion. 

The  organs  of  locomotion  consist  of  the  bones  with  their  appen- 
dages, and  of  the  muscles.  The  bones  which  serve  as  the  base 
and  support  of  all  the  other  parts,  affording  them  strength  and 
stability,  are  the  passive,  while  the  muscles  constitute  the  active, 
organs  of  locomotion. 

I.  The  symptoms  furnished  by  the  bones  are  generally  connect- 
ed with  diseases  which  are  confined  to  these  organs.  They  may 
however  become  the  seat  of  syphilitic  tumors,  scurvy  may  effect 
separation  of  the  cartilages  and  apophyses,  before  complete  bony 
union  has  taken  place,  and  tubercular  disease  may  produce  en- 
largement and  caries. 

The  two  principal  symptoms  of  diseases  of  the  osseous  system, 
are  deformity  of  the  part  and  difficulty  of  motion.  The  former  is 
present  in  nearly  all  fractures  and  dislocations ;  it  is  also  apparent 
in  osteo  sarcoma,  and  particularly  in  rachitis  or  softening  of  the 
bones.  In  the  latter  affection,  the  limbs  are  not  only  incapable  of 
supporting  the  body  in  the  upright  position  and  of  every  kind  of 
regular  motion,  but  they  may  be  bent  by  the  hand  into  any  form. 
Difficulty  or  complete  loss  of  motion,  accompanies  nearly  all  the 
affections  of  these  organs ;  in  some  cases,  voluntary  motion  is 
alone  suspended,  and  the  limb  is  capable  of  receiving  the  motion 
communicated  to  it,  as  in  case  of  fracture ;  in  other  cases,  every 
kind  of  spontaneous  or  communicated  motion  is  impossible,  as  in 
anchylosis  and  some  dislocations. 

Another  not  less  remarkable  phenomenon  is  crepitation  (crepita- 
tio\  a  name  given  to  the  peculiar  sound  occasioned  by  the  friction 
between  the  fragments  of  a  bone,  either  broken,  or  separated  from 
its  apophyses  or  the  cartilages  to  which  it  is  naturally  united. 

A  bone  which  has  been  laid  bare  by  a  wound  or  abscess,  may 
present  to  the  eye  alterations  in  color  and  structure ;  it  sometimes 
becomes  of  a  dull  white  color,  or  presents  a  blackish  tint ;  soften- 
ing of  its  tissue  may  occur,  giving  rise  to  a  more  or  less  abundant 
sanies,  and  causing  it  to  break  down  readily  under  the  pressure  of 
a  blunt  instrument  (caries). 

The  slow  decay  of  a  bone,  in  a  greater  or  less  portion  of  its 
extent,  gives  rise  to  peculiar  symptoms.  This  decay  sometimes 
commences  without  any  known  cause,  as  in  vertebral  disease,  in 
which  it  produces  angular  curvature  of  the  spine.  It  is  by  the 
wearing  away  of  the  sternum  and  ribs,  that  an  aneurismal  tumor 
becomes  apparent  through  the  thoracic  parietes.  The  walls  of  the 
cranium  are  sometimes  worn  away  by  fungous  tumors,  and  by 
gently  depressing  them,  the  bony  circle  which  surrounds  them 
may  be  felt.  In  the  latter  case,  before  the  destruction  of  the  bony 
tissue  is  yet  quite  complete,  the  thin  lamina  which  remains,  if 
compressed,  emits  a  sound  like  that  of  parchment. 
9 


98  SYMPTOMS. 

II.  The  muscles  present  functional  changes  by  far  more  numer- 
ous. Their  action  may  be  increased,  diminished,  destroyed  or 
variously  perverted. 

Increase  of  muscular  strength  has  only  been  observed  in  a  few 
nervous  affections,  and  particularly  in  mania,  in  which  patients 
have  been  known  to  break  the  bonds  which  confine  them,  and 
successfully  resist  many  persons. 

In  most  diseases,  the  force  of  the  contractions  is  diminished  ; 
the  step  is  unsteady,  the  upright  position  painful  or  impossible,  the 
motions  feeble  and  uncertain,  and  often  immediately  followed  and 
even  preceded  by  a  feeling  of  lassitude  :  many  patients  are  obliged 
to  remain  quiet,  and  some  are  unable  to  leave  their  beds.  Among 
the  latter,  there  are  also  those  who  are  unable  to  retain  the  sitting 
posture,  to  feed  themselves,  turn  themselves  in  bed,  and  even  to 
move  their  arms  :  in  extreme  cases,  the  hand  of  the  patient,  hav- 
ing been  raised  and  abandoned  to  itself,  falls  like  an  inert  body, 
obedient  to  the  laws  of  gravity.  This  diminution  of  muscular 
power  occurs,  in  different  degrees,  in  incomplete  paralysis  ;  it  may 
in  this  case  be  confined  to  certain  parts,  like  the  affection  of  which 
it  is  the  symptom.  There  is  a  peculiar  alteration  in  the  muscular 
contractility,  to  which  no  special  name  has  been  given,  but  which 
we  shall  here  notice.  We  refer  to  that  so  constantly  observed  in 
typhoid  fever,  and  which,  often  occurring  at  the  commencement  of 
this  affection,  becomes  one  of  the  most  important  signs  in  its  diag- 
nosis. This  alteration  consists  in  a  kind  of  titubation  or  trembling, 
and  uncertainty  in  the  gait  and  motions  generally,  which  has  been 
justly  compared  to  that  occasioned  by  intoxication. 

The  complete  abolition  of  muscular  contractility  and  voluntary 
motion,  constitutes  paralysis  (paralysis)  ;  *  a  term  applied  to  the 
loss  of  sensation  as  well  as  of  motion,  and  to  the  simultaneous 
abolition  of  both  these  faculties.  Hence,  in  medical  language,  to 
avoid  ambiguity,  the  terms  paralysis  of  motion,  paralysis  of  sen- 
sation^ should  be  employed.  Paralysis  is  general  in  comatose 
affections,  syncope,  asphyxia,  &c.  It  has  been  more  generally 
designated  by  the  term  resolution  des  membres  [resolutio  membro- 
rum].  If  it  affect  but  one  side  of  the  body,  it  is  called  hemiplegia  /j- 
if  the  lower  half,  paraplegia,  or  paraplexia  ;  J  if  the  arm  of  one 
side  and  the  leg  of  the  opposite,  it  is  called  crossed  paralysis, 
which  is  very  rare.  It  is  sometimes  confined  to  one  or  both  wrists, 
as  is  occasionally  observed  in  metallic  colic,  and  more  rarely  in 
typhus.  Paralysis  often  affects  certain  muscles  which  are  devoted 
to  a  particular  kind  of  motion,  as  is  sometimes  observed  in  lead 
colic,  in  which  the  extensors  are  principally  affected,  the  hands 
and  wrists  being  constantly  and  powerfully  flexed.  In  some 
cases,  it  appears  to  affect  but  a  single  muscular  fasciculus  :  this 
has  been  suspected  in  those  cases,  in  which  the  tongue  loses  the 


from  nanalvw,  I  relax. 
f  'HutnlijYia,  (um^r^ta,  from  f^navq,  half,  and  nirjoao),  I  strike. 
,  from  wAijoow,  I  strike  ;  Tracer,  dim.  particle. 


SYMPTOMS.  99 

power  of  articulating  certain  letters,  but  appears  to  retain  all  its 
other  motions.     In  permanent  ptosis,  or  falling  of  the  upper  eyelid 
(collapsus  palpebrce),  the  elevator  muscle  is  alone  paralyzed. 
The  muscular  contractility  may  be  variously  perverted. 

1.  Tremor  consists  in  a  feeble  and  involuntary  agitation,  attrib- 
uted by  most  physiologists  to  alternate  contraction  and  relaxation 
of  the  muscles,  or  alternate  contraction  of  opposite  muscles.     This 
symptom,  which  may  be  general  or  partial,  occurs  in  the  cold 
stage  of  intermittent  fever  and  some  nervous  affections  ;  it  is  often 
produced  by  the  action  of  mercury  and  lead  on  the  economy,  and 
sometimes  by  the  use  of  coffee  and  alcoholic  liquors  ;  it  frequently 
occurs  in  old  persons  from  the  effects  of  age. 

2.  Rigidity  (rigiditas)  should  be  considered  as  a  perversion  of 
muscular  contractility.     The  actual  muscular  power  is,  in  this 
case,  always  diminished,  although  any  attempt  at  communicated 
motion  is  met  with  more  than  ordinary  resistance,  as  will  be  found 
to  be  the  case,  in  attempting  to  draw  the  arm  of  the  patient  out  of 
bed.     This  rigidity  is  evident  to  the  patient  himself;  he  moves  his 
limbs  slowly  and  with  effort.     Rigidity,  like  paralysis,  may  extend 
to  all  the  muscles,  or  be  confined  to  one  side  of  the  body,  one  half 
of  the  face,  or  to  a  certain  few  muscles  ;  it  is  often  connected  with 
some  disease  of  the  brain,  particularly  softening  of  its  substance. 

3.  Cramp  (crampus)  is  a  sudden  but  permanent  contraction  of 
one  or  more  muscles,  accompanied  by  hardness  of  their  tissue, 
numbness  and  inability  to  execute  any  movement  of  the  part  thus 
affected.     The  muscles  forming  the  calf  of  the  leg  are  particularly- 
liable  to  this  affection.     Many  persons  in  health  suffer  from  it;  it 
is  of  frequent  occurrence  in  women  during  the  last  months  of 
pregnancy  ;  it  sometimes  accompanies  hysteria  and  painters'  colic, 
and  is   of  almost  constant  occurrence  in  the  different  species  of 
cholera. 

4.  Subsultus  tendinum  is  a  twitching  communicated  to  the  ten- 
dons by  the  involuntary  and   instantaneous  contraction   of  the 
muscular  fibres.     This  symptom  is  more  observable  at  the  wrist 
than  elsewhere,  and  may  be  felt  by  examining  the  pulse  of  the 
patient.     It  is  common  in  acute  diseases  of  an  ataxic  form. 

5.  Carphologia  *   or  carpologia,  f  consists  in  an  automatic  and 
continual  agitation  of  the  hands  and  fingers,  which,  in  some  cases, 
appear  to  seek  flocculi  in  the  air,  and  in  others,  to  ramble  about 
on  the  bedclothes.     This  symptom,  which  frequently  accompanies 
very  severe  acute  diseases,  sometimes  presents  itself  under  a  differ- 
ent form,  the  patient  continually  endeavoring  to  pick  imaginary 
flocculi  from  the  bedclothes  :  this  is  called  crocidismus,  J  which 
many  authors  have  confounded  with  carphologia. 

6.  Convulsions  (convulsiones)  \\  consist  in  involuntary  contrac- 
ons  of  the  muscles.     They  are  divided  into  clonic  and  tonic.$ 


*  KaQ(prj,  flocculus  ;  *«yo>,  I  collect. 

•j-  KaQTtog,  wrist,  a  part  of  the  hand  ;  I  collect  with  the  hand. 

.   X()oxi(JiLu>.     This  word  signifies  to  pluck  off  the  nap. 

•*•  From  convellere,  to  shake. 

$  Some  authors  have  sought  to  establish  a  distinction  between  convulsion  and 


100  SYMPTOMS. 

i 

A.  dome   convulsions  (spasmi  clonici)  *    consist  in  violent 
and  involuntary  contractions,  which  alternate  with  relaxation  of 
the  contracted   muscles,  or  with  contractions   of   other   muscles. 
The  effects  of  these  convulsions  in  hysterical  females  are  various. 
Some  throw  their  limbs  to  the  right  and  left,  unconsciously  strik- 
ing themselves,  and  rapidly  flexing  and  extending  their  forearms 
and  fingers.     In  others,  particularly  if  the  arms  be  confined,  the 
body  is  alternately  raised  and  depressed  during  the  whole  attack. 
We  saw  at  the  Hospital  Saltpetriere,  in  one  of  the  wards  of  M. 
Landre  Beauvais,  a  young  girl  suffering  from  hysteria,  who,  in 
each  attack,  after  the  ordinary  convulsive  motions  had  passed  off, 
suddenly  and  unconsciously  rose,  and  holding  the  arms  extended, 
rapidly  turned  herself  about,  until  the  supervention  of  another 
paroxysm.     These   were  not  of   long    duration.     We    recollect 
another  case,  that  of  a  young  girl  at  the  Hotel  Dieu,  who,  while 
the  attack  lasted,  rolled  about  upon  the  floor  of  the  ward.     These 
clonic  convulsions  are  not  always  general ;  they  are  sometimes 
partial  in  different  nervous  diseases,  and  even  in  hysteria  and 
epilepsy.     Dr.  Whytt  observed  a  very  curious  example  of  partial 
spasm  in  a  young  girl  aged  eight  years.     The  masseter  and  tem- 
poral muscles   were   alternately  contracted  and  relaxed  and  at 
irregular  intervals,  so  as  to  imitate  the  pulsations  of  the  heart, 
with  this  difference,    that  the  muscular  contractions  were  more 
than  one  hundred  and  forty,  while  the  cardiac  pulsations  were  not 
above  ninety,  in  the  minute.     A  violent  fright  put  an  end  to  this 
affection,   the  cause  of  which  was  unknown,  and  which  resisted 
every  method  of  treatment.     In  connection  with  clonic  convulsions, 
may  be  mentioned  the  involuntary  shaking  of  the  limbs,  to  which 
Gaubius  applied  the  term  palpitatio  membrorum. 

B.  In  tonic  convulsions  (spasmi  tonici^)-\  the  muscular  contrac- 
tion is  permanent,  so  that  the  affected  part  is  in  a  state  of  absolute 
immobility,  which  no  internal  or  external  effort  can  overcome. 
The  equal  and  permanent  contraction  of  all  the  muscles  is  called 
tetanic.J     If  the  anterior  muscles  of  the  body  be  more  strongly  con- 
tracted, causing  flexion  of  the  head  on  the  chest,  and  curvature  of 
the  body  forward,  the  phenomenon  is  called  emprosthotonos ;  \\  if, 
on  the  contrary,  the  body  be  bent  backwards,  so  that  the  back  of 
the  head  approximates  to   the   spine,   it  is  called  opisthotonos.^ 
Lastly,  to  that  variety,  in  which  the  muscles  of  one  side  are  more 
powerfully  contracted  than  those  of  the  opposite,  producing  lateral 

spasm.  They  have  applied  the  term  convulsion  to  those  which  we  have  called 
clonic,  and  the  term  spasm,  to  tonic  convulsions.  But  as  Castelli  observes,  the 
words  spasm  and  convulsion  have  always  been  employed  synonymously,  and  as 
we  have  elsewhere  remarked,  no  change  should  be  made  in  the  acceptation  of 
words  sanctioned  by  custom. 

*  Snanpog,  from  anato,  I  contract ;  xlovog ,  agitation. 

•}•  Tovof,  tension. 

f  TtTavoui,  I  stretch. 

I  'EfinQooBtv,  forward ;  rovog,  tension. 

&  "Omadiv,  backward  ;  TOVOS,  tension. 


SYMPTOMS.  101 

curvature  of  the  body,  the  term  pleurosthotonos  is  applied.*  It 
sometimes  happens  that,  in  tonic  convulsions,  lateral  and  backward 
curvature  of  the  body  take  place  simultaneously,  as  we  had  occa- 
sion to  remark  in  the  case  of  a  young  man  recorded  in  the  Journal 
de  Medecine.  f  Permanent  or  tonic  convulsion  is  not  always 
general,  being  sometimes  confined  to  a  particular  part,  to  the  ele- 
vator muscles  of  the  jaw,  for  example,  and  to  those  which  separate 
the  lips.  In  these  cases  it  is  called  trismus.%  Cynic  spasm  and  the 
risus  sardonicus,  which  have  been  already  mentioned,  are  also 
tonic  convulsions.  || 

C.  Can  the  muscular  fibres  which  enter  into  the  composition  of 
the  stomach,  intestines,  heart  and  urinary  bladder,  become  the  seat 
of  convulsions,  analogous  to  those  observed  in  the  voluntary  mus- 
cles? Among  the  numerous  facts  which  may  serve  to  throw  light 
upon  this  question,  the  emission  of  urine,  of  fecal  matters  and  of 
spermatic  fluid,  in  epileptic  attacks  the  vomiting  which  occurs  in 
hysteria,  and  the  impossibility  of  swallowing,  in  some  varieties  of 
tetanus,  are  phenomena  which  would  incline  us  to  the  belief  that 
this  derangement  of  contractility  may  affect  all  the  muscles, 
whether  voluntary  or  involuntary.  If  in  these  cases  convulsive 
action  be  admitted,  should  it  be  referred  to  the  tonic  or  clonic  con- 
vulsions? This  question,  which  appears  to  us  of  little  importance, 
we  think  entirely  insoluble. 

7.  There  is  another  perversion,  or  anomaly  §  of  muscular  con- 
tractility, which  is  observed  in  catalepsy  (catalepsid) ;  H  in  these 
cases,  the  patient  retains,  during  the  whole  attack,  the  same  posi- 
tion that  he  had  assumed  at  the  time  of  seizure,  or  remains  in  that 
in  which  he  may  be  placed,  however  uncomfortable  it  may  be. 
That  this  is  not  rigidity,  is  evident  from  the  facility  with  which  the 
limbs  are  moved ;  and  the  need  of  relaxation  felt  by  the  muscles  in 
a  state  of  contraction  in  health  is  no  longer  experienced  in  cata- 
lepsy. This  symptom  generally  shows  itself  in  females  suffering 
from  hysteria.  We  have  known  it  to  occur  every  other  day  in  an 
insane  woman.  There  is  a  variety  of  catalepsy  which  we  once 
had  occasion  to  observe,  in  which  the  patient  retained  the  same 
posture  that  he  had  at  the  time  of  the  attack,  but  did  not  preserve 
that  communicated  to  him ;  the  limbs  yielded  to  an  external  force 

*  IIlevQooQev,  laterally  ;  rovog,  tension, 
f  Tome  xxix.  1814. 

JT^trr^og,  gnashing. 
A  curious  symptom  is  mentioned  by  Dr.  Kellie,  in  the  twelfth  volume  of  the 
inburgh  Medical  and  Surgical  Journal,  as  occurring  in  infants  during  dentition. 
It  consists  in  a  spastic  contraction  of  the  flexor  muscles  of  the  thumbs  of  the 
upper,  and  of  the  toes  in  the  lower  extremity,  the  former  being  rigidly  contracted 
and  permanently  bent  downwards,  and  laid  flat  upon  the  palms  of  the  hand,  and 
the  latter  bent  down  to  the  plantar  aspect  of  the  foot.     This  affection  lasted  from 
a  few  days  to  three  months.  —  TRANS. 
$  A  privative,  owuAog,  regular, 
^f    Karalaupavw,  I  seize. 

9* 


102  SYMPTOMS. 

which  placed  them  in  a  new  position,  but  resumed  the  first,  as  soon 
as  the  force  was  withdrawn. 

8.  A  very  remarkable  perversion  of  muscular  contractility  is  ob- 
served in  the  disease  called  St.  Vitus1  Dance  {Chorea  Sancti  Viti). 
If  the  patient  seek  repose,  he  experiences  sudden  twitchings  in  the 
affected  limbs ;  if  he  attempt  to  extend  his  hand  to  any  object,  it 
becomes  affected  by  two  kinds  of  motion,  which  tend  to  draw 
it  in  opposite  directions ;  the  one  voluntary,  by  which  the  patient 
endeavors  to  accomplish  his  purpose ;  the  other,  involuntary  and 
irresistible,  which  opposes  his  efforts ;  so  that  it  is  only  by  a  series 
of  oblique  and  divergent  lines,  that  he  succeeds  in  reaching  the 
object.     The  lower  limbs   may   also  be   similarly   affected,  pro- 
ducing an  irregular  and  unsteady  gait ;  whence  the  term  dance  or 
chorea  which  has  been  applied  to  this  affection. 

9.  There  is  still  another  anomaly  of  muscular  contractility, 
not  less  remarkable;  it  consists  in  being  unable  to  execute  any 
motion  in  a  regular  manner,  unless  with  rapidity.     Such  is  the  case 
with  those  who  are  unable  to  walk,  but  who  run  without  diffi- 
culty ;  so  it  is,  as  Gaubius  remarked,  in  those  who  stutter  when 
speaking  slowly,  but  in  whom  this  peculiarity  disappears  if  they 
articulate  rapidly. 

10.  We  shall,  finally,  notice  contracture  [contractura^    which 
consists  in  permanent   and  chronic  rigidity  of  the   flexor  mus- 
cles.    These  organs,    whose   length   and   thickness  diminish,    at 
the  same  time  becoming  harder,  form  under  the   skin  inflexible 
cords,  which  prevent  the  extension  of  the  limbs.     This  phenome- 
non is  generally  owing  to  a  lesion  in  some  part  of  the  nervous 
system. 

Such  are  the  principal  symptoms  furnished  by  the  active  and 
passive  organs  of  locomotion.  They  aid  in  completing  what  has 
been  already  said  in  regard  to  the  exterior  of  the  body. 


SECTION  THIRD. 

Symptoms  furnished  ly  the  Voice  and  Speech. 

The  voice,  in  health,  is  loud  and  sonorous ;  it  aids,  by  its  inflec- 
tions, in  expressing  the  various  feelings,  which  man  is  capable  of 
experiencing.  The  speech,  or  articulated  voice,  is  ordinarily  free 
and  distinct. 

I.  The  voice  rarely  becomes  stronger  under  the  influence  of  dis- 
ease ;  this,  however,  is  sometimes  the  case  in  delirium.  In  most 
affections,  and  particularly  those  of  the  vocal  and  respiratory  or- 
gans, it  becomes  more  feeble.  It  may  be  entirely  lost,  constituting 
aphonia*  This  symptom  should  not  be  confounded  with  mussi- 
tation  (mussitatio),  in  which  the  tongue  and  lips  move  as  in  the 
act  of  speaking,  without  producing  any  sound ;  these  two  affec- 

*  A  privative,  ywvij,  voice. 


SYMPTOMS.  103 

tions  are  observed  in  some  acute  diseases  ;  they  are  also  of  frequent 
occurrence  in  the  neuroses,  and  particularly  in  hysteria.  Aphonia 
frequently  occurs  in  the  last  stage  of  croup  ;  it  may  also  depend  on 
disease  of  the  brain,  spinal  marrow  or  recurrent  nerves.  When  it 
becomes  chronic,  it  is  generally  owing  to  destruction  of  the  vocal 
cords  by  ulceration,  which  is  almost  always  of  a  syphilitic  or  tu- 
bercular nature,  and  in  the  latter  case  often  co-existing  with 
phthisis  pulmonalis,  as  is  shown  by  the  researches  of  Louis.  We 
should  always  be  led  to  suspect  the  existence  of  this  disease  when 
aphonia  has  persisted  for  several  months,  and  even  when  but  of  a 
few  weeks'  duration  ;  it  is,  in  some  circumstances,  the  first  sign 
that  reveals  it. 

The  voice  may  become  modified  in  tone  as  well  as  strength  ;  it 
is  preternaturally  clear  in  some  malignant  fevers,  and  before,  or 
during  delirium  ;  it  is  shrill  in  certain  forms  of  angina,  whistling 
in  tetanus,  hoarse  in  hydrophobia  and  in  pulmonary  or  laryngeal 
phthisis,  nasal  in  different  affections  of  the  pituitary  membrane, 
and  discordant  in  certain  diseases  of  the  larynx,  as  was  observed 
by  Portal  in  the  case  of  a  woman  whose  voice,  while  speaking, 
became  alternately  shrill  and  hoarse.  In  some  varieties  of  melan- 
choly, the  voice,  like  the  attitude  of  the  patient,  is  in  imitation  of 
that  of  certain  animals,  as  the  dog  and  wolf;  these  varieties  of  mel- 
ancholy have  consequently  received  the  names  cynanthropia  *  and 
lycanthropia.  \  Lastly,  it  has  been  observed  that  deafness  effects 
a  change  in  the  voice,  which,  being  no  longer  regulated  by  the  ear, 
becomes  altered  in  its  tone  and  inflections. 

II.  The  speech  presents  certain  alterations,  which  may  accom- 
pany those  of  the  voice,  or  be  manifested  alone. 

1.  In  certain  grave  fevers,  the  words  are  pronounced  in  a  hesi- 
tating and  trembling  voice  (vox  tremuld). 

2.  Stammering  (balbuties)  is  a  defect  of  speech  which  prevents 
the  free  articulation  of  certain  letters  or  syllables  which,  after  an 
effort   to   pronounce   them,   are  quickly  repeated;  this  occurs  in 
some  diseases  of  the  brain  and  in  grave  fevers.     It  is.  as  is  well 
known,  natural  to  some  persons,  and  undoubtedly  connected  with 
some  defect  of  organization. 

3.  Articulation  is  slow  in  many  diseases  ;  prompt  in  others.     In 
others  there  is  great  fluency  of  speech.     The  latter  symptom  was 
observed  by  Senac  several  times  at  the    commencement  of  the 
paroxysms  in  intermittent  fevers. 

4.  Portal  had  under  his  care  a  woman  who  commenced  speak- 
ing with  difficulty,  but  was  unable  to  keep  silent  after  uttering 
the  first  words  :  she  was  compelled  to  express  by  words  all  the 
thoughts  that  occurred  to  her,  even  when  at  church.     This  was 
the  same  patient  in  whom  the  discordance  of  sounds,  which  we 
have  just  mentioned,  was  noticed.     There  is  a  similar  case,  at 
present,  in  Paris. 


,  dog  ;  ai&Qojrroe,  man. 
,  wolf;  UV&QWTIOS,  man. 


104  SYMPTOMS. 

5.  Loss  of  speech  may  exist  independently  of  that  of  the  voice, 
as  is  observed  in  dumbness,  which  consists  in  an  inability  to 
produce  articulate  sounds.  The  loss  of  the  voice,  on  the  contrary, 
is  always  accompanied  by  that  of  speech.  The  latter  has  been 
observed  previous  to  apoplexy  and  in  nervous  diseases.  It  is 
sometimes  the  effect  of  poisoning.  Sauvages  relates  that  the 
robbers  in  the  vicinity  of  Montpellier,  caused  their  victims  to 
drink  wine  in  which  had  been  infused  the  seeds  of  the  thorn 
apple ;  this  narcotic,  according  to  that  physician,  produces  a 
transient  dumbness,  which  gave  the  robbers  sufficient  time  to 
escape. 

The  peculiar  method  of  exploration,  to  which  Laennec  has 
given  the  name  auscultation*  applied  to  the  voice,  led  that  phy- 
sician to  the  discovery  of  still  other  interesting  phenomena,  which, 
render  the  diagnosis  of  many  frequent  and  grave  diseases  much 
more  complete.  These  symptoms  will  be  considered  in  connection 
with  those  which  belong  to  respiration  ;  we  have  thought  it  better 
to  consider  all  the  phenomena  furnished  by  the  auscultation  of  the 
respiratory  passages  in  the  same  article. 


SECTION   FOURTH. 

Derangements  of  Sensibility  and  of  Sensation,  considered  as  Symptoms, 

The  faculty  of  feeling  is,  in  the  natural  state,  imparted,  vari- 
ously modified,  to  many  organs;  it  may,  as  is  well  known, 
become  developed,  under  the  influence  of  disease,  in  all  the  others, 
with  the  exception  of  the  epidermis  and  its  productions.  It  is  by 
virtue  of  this  faculty  that  different  impressions  are  transmitted  to 
the  sensor ium  commune  ;  some,  called  internal  sensations,  inform 
us  of  certain  phenomena  which  are  taking  place  within  our 
bodies;  others,  to  which  the  term  sensations  has  been  particularly 
applied,  acquaint  us  with  certain  conditions  or  qualities  of  exter- 
nal objects  about  us.  The  faculty  of  feeling,  considered  generally, 
and  the  sensations,  both  internal  and  external,  present  under  the 
influence  of  disease,  numerous  changes  which  we  shall  proceed 
to  examine. 

I.  The  derangements  of  sensibility  which  occur  in  disease, 
have  been,  by  many  physicians,  considered  as  the  effect  of  an 
unequal  distribution  of  this  faculty.  Excessive  pain  in  any  parr., 
they  suppose  to  be  the  result  of  a  morbid  accumulation  of  sensi- 
bility, which  in  some  subjects  constantly  takes  place  in  some  par- 
ticular organ,  and  in  others,  successively  in  different  parts.  This 
theory  does  not  appear  to  us  to  accord  with  facts.  If  there 
be  some  individuals  in  whom  the  sensibility,  when  augmented  in 
any  part,  becomes  diminished  in  all  others,  this  is  by  no  means 

*  From  auscultate,  to  listen. 


SYMPTOMS. 


105 


the  case  in  the  greatest  number.  It  generally  happens,  as  has 
been  observed  in  hypochondria  and  hysteria,  that  the  sensibility 
is  diminished  or  increased  in  all  the  organs  at  once  :  it  is  equally 
augmented  in  all  parts  during  the  first  period  of  certain  acute 
cerebral  affections  ;  it  becomes  everywhere  simultaneously  dimin- 
ished, and  even  extinct,  in  the  second  and  third  periods  of  these 
affections. 

Loss  of  sensibility  is  often  connected  with  that  of  muscular 
contractility,  particularly  in  cases  where  there  is  also  loss  of  con- 
sciousness :  the  same  cause,  as  compression  of  one  of  the  cerebral 
hemispheres,  may  produce  both  these  effects.  There  is  then  pa- 
ralysis of  motion  and  of  sensation.  In  many  cases  of  cerebral  com- 
pression, in  which  there  is  a  diminution  or  entire  suspension  of 
motion,,  the  faculty  of  it  is  preserved,  as  also  in  some  rare  affec- 
tions, whose  material  cause  is  unknown,  the  muscles  preserve 
their  contractility,  while  the  integument  that  covers  them  is 
deprived  of  feeling.  Some  very  ingenious  researches  have  been 
recently  undertaken,  with  a  view  to  throw  light  upon  this  point 
in  pathology  :  these  led  to  the  supposition  that  the  exclusive  office 
of  the  anterior  and  posterior  fasciculi  of  which  the  medulla 
oblongata  and  spinalis  are  composed,  is  to  transmit,  the  one 
motion  and  the  other  sensation,  so  that  lesions  confined  to  either 
one  or  the  other,  or  to  the  parts  from  which  they  take  their  origin, 
produce  derangement  alone  of  one  or  the  other  of  these  func- 
tions, while  those  which  affect  both  these  nerves,  or  the  whole 
spinal  cord,  would  produce  simultaneous  derangement  of  motion 
and  sensation.  In  support  of  this  opinion,  may  be  mentioned 
certain  cases  communicated  to  the  Academy  of  Medicine,  or  pub- 
lished in  the  periodical  collections ;  but  these  facts,  which  have 
been  contradicted  by  other  experimenters,  are  yet  too  limited  in 
number,  and  require  further  confirmation. 

II.  The  internal  sensations,  in  the  healthy  individual,  chiefly 
consist  in  the  wants  connected  with  the  regular  exercise  of  the 
functions ;  in  disease,  these  wants,  together  with  the  functions  on 
which  they  depend,  become  deranged ;  other  sensations  also  man- 
ifest themselves,  which  belong  exclusively  to  disease,  and  which 
demand  the  attention  of  the  physician  ;  such  are  the  various  kinds 
of  pain. 

As  the  nature  of  pain  is  familiar  to  all  from  experience,  it  will 
be  useless  to  attempt  its  definition. 

Pain  may  be  produced  by  various  causes  with  which  we  are  but 
partially  acquainted ;  its  effects  may  be  less  difficult  to  appre- 
ciate ;  it  varies  in  its  nature,  intensity,  type,  and  seat. 

The  causes  productive  of  pain  in  diseases  are  :  1,  considerable 
alterations  in  the  tissue  of  parts  which  are  its  seat,  as  wounds, 
inflammations,  ulcerations,  and  organic  affections ;  2,  a  too  vio- 
lent or  long  sustained  action ;  3,  an  inexplicable  modification  in 
the  motion  of  organs  which  become  primarily  or  sympathetically 
painful,  without  any  manifest  cause. 

The   effects  of  pain   are   generally  more   apparent :  1,  it  de- 


106  SYMPTOMS. 

ranges  the  functions  of  the  suffering  organ ;  in  the  muscle,  it  ob- 
structs or  hinders  the  motions,  in  the  mouth,  affecting  mastica- 
tion, in  the  thorax,  respiration ;  2,  it  also  determines,  in  some 
cases,  an  afflux  of  fluids,  either  to  the  surface  or  tissue  of  organs ; 

3,  it  may  produce  sympathetic  disturbance  in  distant  parts,  as 
vomiting  in  headache,   and  convulsions  in   many  kinds  of  pain ; 

4,  it  may  cause,  when  occurring  in  its  highest  degree  of  intensity, 
disorder  of  nearly  all  the  functions,  arid  when  prolonged   may 
result  in  death. 

Pain  may  exist  variously  modified ;  each  of  its  principal  vari- 
eties has  received  particular  names  :  1,  that  which  consists  in  a 
feeling  of  distension,  has  been  called  tensive  ;  it  occurs  especially 
in  phlegmonous  inflammation;  2,  a  heavy  pain  is  a  feeling  of 
weight  which  accompanies  collections  of  fluid  in  natural  or  acci- 
dental cavities,  and  which  is  sometimes  felt  in  many  other  affec- 
tions ;  3,  a  throbbing-  pain  is  marked  by  its  pulsations  which  are 
isochronous  with  those  of  the  heart ;  it  is  felt  particularly  in 
inflammatory  tumors,  in  which  suppuration  is  about  to  take  place; 
4.  lancinating  pain  is  characterized  by  transient  lancinations  or 
shootings  which  do  not  correspond  to  the  arterial  pulsations  ;  this 
kind  of  pain  is  peculiar  to  cancer  and  neuralgia ;  5,  a  boring  pain 
has  been  admitted,  because  those  who  experience  it,  compare  it  to 
the  sensation  which  a  wimble  or  screw  would  produce  in  entering 
and  turning  on  itself  in  the  suffering  part ;  it  is  felt  in  some  cases 
of  rheumatism ;  6,  a  contusive  pain  resembles  that  produced  by  a 
bruise :  it  frequently  occurs  among  the  precursory  phenomena  of 
acute  diseases ;  7,  the  pain  which  is  felt  in  anthrax  arid  in  gan- 
grenous erysipelas,  is  compared  by  patients  to  that  produced  by 
the  contact  of  ignited  bodies  ;  this  has  been  termed  burning  pain ; 

8,  the  prurigenous  pain,  or  itching,  occurs  in  diseases  of  the  skin  ; 

9,  there   is  another  kind   of  pain,  which   is   called  formication 
(formicatio),  from  its  resemblance  to  the  sensation  which  would 
be  caused  by  a  multitude  of  ants  creeping  over  the  part.     Finally, 
pain  may  be  tearing  or  pungent.     Some  patients  compare  their 
sensations  to  a  wound  whose  edges  have  been  removed,  or  the 
surface  of  which  has  been  irritated  by  some  mechanical  agent ; 
others,  to  compression  of  the  part  by  an  iron  band,  or  the  fall  of  a 
heavy  weight  upon  it,  &c.     Pain  may  become  changed  in  char- 
acter in  the  course  of  a  disease  :  thus,  in  the  first  stage  of  phleg- 
mon it  is  tensive,  in  the  second,  throbbing,  and  heavy,  when  sup- 
puration has  taken  place. 

Pain  varies  in  its  degree  of  intensity :  this  may  be  determined 
by  the  report  of  the  patient,  his  expression  of  countenance,  and 
the  functional  derangement  it  occasions.  It  may  depend  upon  the 
cause  which  produced  it,  or  the  sensibility  of  the  individual  and 
particularly  of  the  suffering  organ.  It  is  increased  and  diminished 
under  different  circumstances  ;  it  is  sometimes  aggravated  by  heat, 
at  others,  by  cold ;  in  the  one  case  it  is  excited,  in  the  other,  mod- 
erated by  external  pressure ;  prolonged  movement  in  the  former 
in  the  latter,  diminishes  it.  The  expression  of  the 


SYMPTOMS.  107 

physiognomy,  under  the  influence  of  pain,  varies  with  the  constitu- 
tion and  character  of  the  patient. 

The  type  of  pain  is  sometimes  continuous,  with  or  without 
exacerbation,  sometimes  intermittent,  with  or  without  regularity. 
In  the  first  case,  the  pain  is  uninterrupted,  and  of  different  or 
equal  intensity ;  in  the  second,  it  ceases  and  reappears  at  regular 
or  irregular  intervals.  Every  pain  which  is  reproduced  without 
one  of  the  types  peculiar  to  intermittent  fever,  and  the  duration  of 
which,  at  each  return,  is  about  the  same  as  that  of  a  paroxysm, 
deserves  particular  attention,  as  it  is  generally  due  to  the  same 
causes  which  produce  intermittent  fevers,  and  will  yield  to  the 
same  treatment. 

There  are  certain  pains,  which  are  felt  simultaneously  in  all 
parts  of  the  body,  as  those  which  precede  arid  accompany  the 
invasion  of  some  acute  diseases ;  but  they  are  generally  partial, 
and  even  confined  to  a  limited  portion  of  the  body.  In  some  cases, 
they  remain  seated  in  the  same  place,  in  which  case  they  are 
termed  fixed ;  in  others,  they  change  their  seat  once  or  more ; 
these  being  called  vague  or  movable.  *  Fixed  pains  should 
always  arouse  the  attention  of  the  physician,  for  they  are  often 
indicative  of  important  visceral  changes.  Thus,  a  circumscribed 
and  continuous  pain  in  the  head,  occurring  in  old  persons,  often 
proceeds  from  cerebral  softening,  in  its  incipient  stages. 

There  are  certain  other  painful  sensations,  which,  though  not 
exactly  corresponding  to  pain,  closely  resembles  it:  such  are  the 
general  uneasiness  and  inquietude  which  accompany  different  dis- 
eases ;  such  also  is  anxiety  which  consists  in  extreme  uneasiness, 
often  more  uncomfortable  and  insupportable  than  acute  pain,  and 
which,  though  generally  felt  throughout  the  whole  body,  is  partic- 
ularly referred  to  the  epigastric  region,  obliging  the  patient  contin- 
ually to  change  his  position.  The  highest  degree  of  anxiety  is 
anguish,  which  is  ordinarily  attended  by  palpitations,  dyspnoea, 
and  a  change  in  the  expression  of  the  features  and  plaintive  res- 
piration ;  such  are  also  those  internal  movements  attributed  by 
patients  to  the  displacement  of  some  viscus,  to  some  foreign  body, 
and  often  to  a  ball  or  globe  (globus  hystcricus),  which,  rising  from 
the  hypogastric  region  or  the  left  side,  seems  to  ascend  to  the 
pharynx,  producing  a  sense  of  suffocation. 

*  Pain  has  received  different  names,  according  to  the  portion  of  the  body  which  is 
its  seat.  Cephalalgia  (xetpaVi^  head,  alyog,  pain)  signifies  pain  in  the  head  ;  her- 
micrania  (i'^«n/$,  half,  xQanor,  head)  hy  corruption  migraine,  that  confined  to  one 
of  its  sides,  &c  ;  to  cephalalgia  is  applied  the  epithet  frontal,  supraorbitar,  synci- 
pital  occipital,  when  it  is  exclusively  confined  to  either  of  these  regions.  Pain  in 
the  ear  is  called  otalgia  (  <»?,  WTO?,  ear) ;  that  of  the  teeth  odontalgia  (odov$,  oSov- 
TOC,  tooth).  By  the  term  point  de  coti  (stitch  in  the  side)  is  understood  a  pain 
occupying  the  lateral  part  of  the  chest.  Pain  situated  in  the  epigastric  region 
has  received  various  appellations,  as  cardialgia  (xandia,  orifice  of  the  stomach), 
cardiogmus  (xao<Jtu>yi/o?,  pain  of  the  cardia),  epigastralgia  (tTti,  upon,  yanrrg, 
belly).  Pain  in  the  intestines  is  known  by  the  name  colic  (xu>Aov,  colon).  Those 
of  the  kidneys,  liver,  and  spine,  have  been  termed  by  some  authors,  nephralgia 
(veifQog,  kidney),  hepatalgia  (»;/iap,  liver,)  rachialgia  (()a/«s,  spine).  Pain  seated 
in  the  nerves  is  called  neuralgia  (rsvyw,  nerve),  and  that  felt  in  the  bones 
osteocopus  (oartov,  bone,  AOTJTW,  I  break.) 


108  SYMPTOMS. 

To  this  same  series  of  symptoms,  might  be  added  the  sensation 
of  cold  or  heat,  which  some  persons  experience  in  the  whole  or  a 
part  of  the  body  ;  but  the  consideration  of  the  changes  in  animal 
heat,  more  naturally  belongs  elsewhere. 

III.  External  sensations.  In  health,  the  organs  of  sense  receive 
the  impression  of  external  objects,  and  transmit  it,  with  prompt- 
ness and  precision,  to  the  brain ;  under  the  influence  of  disease, 
these  impressions  may  become  wearisome,  the  perception  confused, 
irregular  or  defective.  Derangement  of  the  sensations  is  some- 
times produced  by  an  affection  of  the  organ  which  is  its  seat,  and 
sometimes  by  the  connection  or  association  which  may  exist 
between  that  organ  and  the  suffering  part. 

The  sight,  hearing,  taste  and  touch,  may  suffer  the  same  de- 
rangements as  other  functions,  as  exaltation,  diminution,  abolition, 
and  the  various  perversions,  among  which  authors  have  classed 
hallucinations,  and  illusions  of  the  senses.  But,  as  Esquirol*  has 
justly  remarked,  in  hallucinations,  the  mind  is  the  sole  seat  of  the 
affection  ;  those,  thus  affected,  indulge  in  day-dreams,  their  dis- 
ordered brains  giving  a  body  and  reality  to  images  reproduced  by 
the  memory,  or  created  by  the  imagination,  without  the  interven- 
tion of  the  senses.  In  illusions,  on  the  contrary,  the  patient  is 
deceived  in  regard  to  the  nature  and  cause  of  his  real  sensations. 
Illusions  are  not  uncommon,  even  when  the  nervous  system  and 
organs  of  sense  are  free  from  disorder ;  but  they  are  perceived  by 
the  reason,  and  by  it  the  patient  is  enabled  to  guard  against  them. 
The  case  is  different  with  the  sick,  and  particularly  the  insane 
man,  whose  reason  is  often  at  fault,  and  whose  sensations  are  con- 
sequently received  as  real,  and  as  conveying  no  false  impression. 

A.  Exaltation  of  vision  occurs  in  ophthalmia,  in  inflammation 
of  the  retina,  and  of  the  meninges ;  dimness  of  vision  takes  place 
in  typhus,  &£.;  its  entire  abolition,  in  blindness,  amaurosis,  cata- 
ract and  certain  nervous  affections.  The  sight  is  sometimes  singu- 
larly perverted  :  1.  ft  may  exhibit  objects  which  have  no  real 
existence,  as  sparks  of  fire,  flashes,  floating  specks  or  spots  resem- 
bling flies,  cobwebs,  light  shadows,  &c.,  (metamorphopsia). 
2.  It  may  change  the  color,  form,  and  number  of  objects  presented 
to  the  eye  :  thus  in  plethora  and  internal  ophthalmia,  objects  some- 
times appear  of  a  red  color ;  and  during  the  first  few  days  of 
jaundice,  they  are  said  to  be  colored  yellow ;  in  certain  neuroses, 
in  some  forms  of  amaurosis,  and  in  incipient  cataract,  only  one 
half  or  a  portion  of  the  object  is  visible :  this  is  called  hemiopsia  * 
(visus  dimidiatus)  \  in  other  cases  they  appear  double  :  this  is 
diplopiaf  or  double  vision  (visus  duplicates),  which  is  ordinarily 
only  observed  when  the  two  eyes  are  open ;  in  a  very  remarkable 
case  related  by  Maurice  Hoffman,  however,  it  persisted  when  one 

*  ESQUIROL,  des  Illusions  chez  les  alienes,  a  paper  read  at  the  Acadamie  des 
Sciences,  1832 

•-///tiov$,  half;  oTirouai,  I  see. 
j  double  ;  w'V'  eye. 


SYMPTOMS.  109 

eye  was  closed.  *  This  affection  rarely  exists,  without  strabismus ; 
if  the  want  of  concordance  of  the  optic  axes  be  not  at  first  appa- 
rent, it  will  become  evident  if  the  patient  be  directed  to  turn  his 
eyes  successively  to  the  right  and  left,  and  upward  and  downward. 

B.  The  hearing  becomes  frequently   acute  in  meningeal  in- 
flammation, &c. ;  obtuse  in  typhus  and   grave  fevers ;   it   is  not 
entirely  abolished  except  in  diseases  of  the  ear,  as  chronic  otitis 
with  caries,  and  perforation  of  the  tympanum,  lesions  which  not 
uncommonly  occur  after  variola,  typhoid  fever,  and  in  the  latter 
stages  of  phthisis  pulmonalis.     The  hearing  may  be  perverted  in 
two  ways  ;  in  one  case,  the  patient  imagines  he  hears  sounds, 
which  have  no  existence,  as  beatings,  tinnitus,  the  ringing  of  bells, 
the  noise  of  the  wind,  the  murmur  of  water,  the  music  of  some 
instrument,  words  and  even  speeches ;  in  the  other,  he  does  not 
properly  appreciate  the  sounds  which  he  really  hears,   they  ap- 
pearing to  him  more  acute  or  grave  than  they  really  are  j  and  he 
does  not  recognize  the  voice  of  his  friends. 

C.  The  exaltation  of  smell  has  been  observed  in  the  neuroses 
and  some  other  diseases.     Bally  relates  that  when  suffering  from 
yellow  fever  at  St.  Domingo,  he  distinguished,  in  the  cold  water 
which  he  drank,   the  odor  of  the  flowers  which  grew  upon  the 
banks  of  the  stream  from  whence  it  was  drawn.     Diminution   of 
this  sense  is  much  more  frequently  observed,  as  in  coryza,  ozaena, 
and  all  the  acute  diseases  in  which  the  pituitary  membrane  be- 
comes deprived  of  its  moisture.     If  this  membrane  be  entirely  dry, 
the  sense  of  smell  no  longer  exists.     In  some  cases  of  ataxic 
fevers,  and  in  the  lighter  forms  of  hysteria,  the  patient  complains 
of  smelling  odors  which  in  fact  do  not  exist,  or  perceives  in  sub- 
stances a  different  smell  from  that  which  belongs  to  them. 

D.  The  taste  is  rarely  exalted  in  disease ;  this  symptom  has 
however  been  observed  in  the  neuroses.     It  is  diminished  in  nearly 
all  acute  affections,  and  often  suspended  in  the  last  stage  of  grave 
fevers   in   which   patients  take  without    repugnance    the    same 
remedies  which  had  before  excited  nausea  from  having  merely 
swallowed  them.     This  sense  also  presents  other  anomalies ;  some 
patients  perceive  an  acid,  bitter,  saltish,  coppery,  or  putrid  taste 
in  all  their  food,  whether  liquid  or  solid ;  to  others,   substances 
which  are  disgusting  or  insipid,  have  a  delicious  flavor,  while  food 
of  a   superior   flavor  is   to   them   positively  disagreeable.     This 
symptom  is  particularly  observable  in  hysteria. 

E.  The  touch,  taken  in  its  most  limited  acceptation,  rarely 
furnishes  many  remarkable  symptoms ;  it  may  be  diminished  or 
abolished ;  it  is  rarely  depraved.     Sarcone  remarked,  in  the  epi- 
demic of  Naples,  that,  of  all  the  senses,  this  was  least  affected. 

*  Ephem.  Natur.   Curios.,  vol.  ii.,  obs.  1. 
10 


110  SYMPTOMS. 

Taken  in  a  more  general  sense,  this  sense  may  be  exalted  in  the 
whole  or  a  part  of  the  body,  as  in  general  nervous  affections,  and 
in  local  phlegmasise.  It  becomes  more  or  less  diminished,  or 
completely  abolished,  in  apoplexy,  paralysis  of  sensation  ;  it  may  be 
perverted,  the  patient  incorrectly  appreciating  real  sensations,  or 
experiencing  those  which  are  imaginary,  as  in  the  sensation  of  a 
drop  of  water  falling  upon  some  part  of  the  body,  a  pin  penetrat- 
ing the  skin,  or  the  crawling  of  some  animal  over  the  body  ;  but 
these  last  phenomena  belong  to  hallucinations,  as  well  as  to  illusions 
of  the  senses,  and  constitute  one  of  the  signs  of  a  disordered 
intellect. 


SECTION    FIFTH. 
Symptoms  furnished  by  the  Affective  Functions. 

These  functions,  in  health,  present  the  greatest  variety  in  differ- 
ent individuals. 

Disease  almost  always  produces  a  degree  of  sadness  or  impa- 
tience, ennui  or  inquietude.  All  these  effects  may  be  produced 
simultaneously,  or  successively,  but  in  most  cases,  the  derange- 
ment of  the  affective  functions  is  more  manifest.  They  are  some- 
times exalted,  as  is  observed  in  hypochondriacs;  patients  thus 
affected  are  at  once  susceptible  of  the  strongest  attachment  and  the 
most  profound  hatred  ;  the  least  evidence  of  good  will  affects  them 
to  tears,  and  on  the  slightest  occasion  they  will  form  the  blackest 
suspicions.  In  others,  the  opposite  is  observed  ;  they  appear  indif- 
ferent to  their  own  fate,  and  that  of  their  nearest  friends  ;  in  some 
cases  of  typhoid  fever  and  mania,  the  moral  sensibility  is  almost 
entirely  abolished.  The  character  and  affections  may  be  perverted r; 
persons  who  in  health  are  the  most  amiable,  become  peevish  ; 
those  most  imperious  and  obstinate,  docile ;  the  most  resolute, 
pusillanimous ;  and  the  timid,  resigned  and  even  courageous, 
under  the  influence  of  disease.  This  has  not  escaped  the  observa- 
tion of  those  unconnected  with  the  profession,  and  it  is  a  common 
remark,  that  those  who  in  health  are  the  most  amiable,  are  the 
worst  patients.  Disorder  of  the  moral  affections  is  still  more  mani- 
fest in  some  individuals,  who,  during  a  part  or  the  whole  course 
of  a  disease,  take  an  aversion  to  their  nearest  and  most  intimate 
friends.  This  symptom  is  not  unfrequently  observed  in  hypochori- 
driasis  and  mania. 


SYMPTOMS.  Ill 

SECTION  SIXTH. 

Symptoms  furnished  by  the  Intellectual  Functions. 

The  intellectual  functions  relate  principally  to  the  attention, 
memory,  imagination  and  judgment ;  these  presenting,  in  health, 
infinite  varieties,  and,  in  disease,  being  susceptible  of  numerous 
alterations.  In  some  cases,  there  is  perversion  of  the  judgment  and 
imagination,  while  the  attention  and  memory  remain  unaffected ; 
in  others,  the  memory  is  alone  at  fault ;  but  generally  all  these 
functions  are  simultaneously  deranged. 

Exaltation  of  the  intellectual  powers  is  a  prominent  symptom  in 
some  patients,  and  particularly  in  melancholies  ;  we  are  often 
struck  with  the  clearness  and  surprising  accuracy  of  the  memory 
by  which  they  are  enabled  to  recollect  events  long  since  forgotten, 
the  appropriateness  and  precision  of  their  language,  their  rapidity 
and  strength  of  judgment,  and  fertility  of  imagination,  in  short, 
a  degree  of  intelligence  far  surpassing  that  which  they  ordinarily 
possess  when  in  health.  Nor  is  it  rare  to  observe  an  extraordinary 
development  of  the  intellectual  functions,  connected  with  exalta- 
tion of  the  moral  sensibility,  in  acute  disease  about  to  terminate 
fatally.  The  dying  often  speak  with  an  eloquence  which  they 
were  not  before  known  to  possess,  and  express  sentiments  which 
they  did  not  appear  susceptible  of  experiencing. 

The  intellectual  functions  are  more  often  enfeebled  than  exalted 
in  disease.  This  diminution  of  the  intellectual  powers,  occurs  in 
most  diseases,  particularly  those  of  an  acute  character.  It  is  prin- 
cipally in  typhus  that  this  symptom  is  noticed ;  it  is  difficult  to  fix 
the  attention  of  the  patient ;  he  comprehends  with  difficulty  the 
questions  that  are  put  to  him,  replying  slowly,  and  having  but  a 
vague  idea  of  what  is  going  on  around  him,  the  place  where  he  is, 
or  his  relations  to  those  about  him ;  his  physiognomy  is  not  in 
harmony  with  surrounding  circumstances ;  his  attention  is  not 
directed  towards  the  object  that  excites  it ;  his  features  are  without 
expression,  and  the  body  remains  in  one  posture. 

There  is  an  entire  absence  of  the  intellectual  faculties  in  idiocy, 
and  those  diseases,  in  which  there  is  a  suspension  of  all  the  func- 
tions of  relation,  as  violent  apoplexy,  and  epilepsy. 

Perversion  of  one  or  more  of  the  intellectual  or  affective  faculties 
constitutes  delirium.* 

This  affection  is  more  likely  to  occur  during  childhood  and 
youth  than  at  any  other  period  of  life,  and  in  persons  of  great  ner- 
vous susceptibility.  There  are  some  individuals,  in  whom  a  slight 
indisposition,  or  febrile  attack,  is  accompanied  with  this  affection. 
But  this  symptom  does  not  generally  occur,  except  in  severe  acute 
diseases,  or  in  chronic  affections  when  drawing  towards  a  fatal 
close. 

*  Delirium,  de,  from  ;  lira,  ridge  between  two  furrows. 


112  SYMPTOMS. 

Delirium  does  not  alone  occur  in  affections  of  the  brain  and  its 
membranes  ;  it  is  more  often  observed,  as  a  sympathetic  phenome- 
non, in  the  thoracic  and  abdominal  phlegmasise,  eruptive  fevers,  the 
various  kinds  of  typhus,  and  in  typhoid  fever.  It  is  with  the  brain 
as  with  the  heart,  these  two  viscera  being  associated  with  the 
affections  of  all  others,  and  the  disturbance  of  their  functions  being 
generally  sympathetic.  This  subject  will  be  again  considered  in 
the  chapter  on  diagnosis. 

Delirium  may  present  itself  under  various  forms ;  it  generally 
appears  in  the  relations  of  the  patient  with  external  objects,  in  his 
gestures,  actions,  and  in  the  words  by  which  he  expresses  his  ideas 
of  surrounding  circumstances;  but  there  is  also  an  internal  deliri- 
um, sometimes  observed,  which  depends  solely  upon  disorder  of 
the  cerebral  functions,  and  is  not  excited  by  any  external  circum- 
stance ;  it  is  characterized  by  muttering,  carphologia,  automatic 
gestures,  conversations  with  absent  persons,  &c. 

There  is  a  state  of  complete  delirium  in  which  the  order  of  ideas 
and  moral  affections  is  entirely  perverted,  the  patient  being  contin- 
ually in  error  on  every  subject;  this  is  observed  in  mania.  In 
other  cases  the  disease  affects  but  a  single  idea.  This  is  partic- 
ularly observable  in  monomania,  (melancholy  of  Pinel,)  the  patient 
entertaining  erroneous  ideas,  as  to  his  rank,  the  place  where  he 
is,  and  the  passage  of  time ;  and  consequently  speaking  and  acting 
in  accordance  with  this  error.  In  complete,  as  in  partial  delirium, 
there  is  sometimes  a  predominant  idea,  which  almost  always  relates 
to  the  habitual  occupation  of  the  patient,  as  is  particularly  noticed 
in  coachmen,  errand  boys,  &c.  It  has  been  observed  that  in  those 
cases  which  present  a  predominant  idea,  it  is  almost  impossible  to 
dispel  it,  or  to  excite  others  in  its  place. 

Delirium  may  be  constant,  or  transient ;  in  the  latter  case  it  may 
recur  at  regular  intervals. 

The  two  principal  varieties  of  this  affection,  which  have  been 
particularly  described  by  authors,  are  the  mild  or  tranquil  and 
furious  delirium. 

Mild  delirium  (subdelirium)  can,  in  some  cases,  only  be  distin- 
guished by  a  change  in  the  gestures,  actions,  and  language  of  the 
patient ;  he  tosses  his  arms  to  and  fro  without  any  determinate 
object ;  tries  to  get  out  of  bed,  or  uncover  himself;  he  at  one  time, 
preserves  an  obstinate  silence  (taciturnetas,)  and  at  another,  talks 
incoherently  (vaniloquium)  or  mutters  unintelligibly  between  his 
teeth.  We  have  seen  a  case  in  which  delirium  could  only  be  dis- 
tinguished by  the  plaintive  cries  constantly  uttered  by  the  patient. 
To  most  questions  which  were  put  to  him,  he  replied  promptly ; 
but  when  asked  why  he  thus  complained,  he  appeared  unable  to 
comprehend  the  question.  Mild  delirium  may  also  show  itself,  by 
a  more  or  less  marked  alteration  in  the  physiognomy,  sound  of  the 
voice,  and  in  the  mild,  or  severe,  free,  or  respectful  mode  of  ex- 
pressing himself,  being  not  in  accordance  with  the  usual  manner 
of  the  patient.  It  is  not  uncommon  for  them  to  speak  harshly  to 
those  whom  they  have  generally  treated  with  respect,  and  vice 


SYMPTOMS.  113 

versa,  having  no  recollection  of  the  circumstance  after  recovery. 
In  the  case  of  a  young  man  sick  with  typhus  fever,  who  was  under 
our  care,  the  patient  nearly  recovered  his  senses  about  the  twelfth 
day,  the  only  evidence  of  any  remaining  delirium  being  the  famil- 
iar tone  with  which  he  addressed  an  old  friend  of  his  family  for 
whom  he  had  always  shown  proper  respect.  Tranquil  delirium 
should  not  be  confounded  with  those  distressing  dreams  which 
occur  during  sleep,  and  which  cease  upon  arousing  the  patient. 

Furious  delirium  presents  itself  under  a  totally  different  form  ; 
the  patient  shouting,  singing  and  uttering  threats ;  talking  in  the 
most  obscene  and  extravagant  manner,  railing  against  absent  per- 
sons, quarreling  and  trying  to  leave  his  bed,  throwing  from  him  any 
object  he  can  lay  hold  of,  spitting  upon,  and  striking  his  assistants, 
&c.  The  same  patient  may  be  alternately  affected  with  mild  and 
furious  delirium.  In  the  epidemic  of  Naples,  according  to  Sarcone, 
furious  delirium  ceased  during  the  remission;  but  the  patients 
abandoned  themselves  to  the  most  frightful  despair,  turning  their 
eyes  with  a  suspicious  air  upon  their  assistants,  fearing  to  read  in 
their  countenances  the  unhappy  fate  with  which  they  believed 
themselves  threatened  ;  the  least  sign  of  affection  caused  them  to 
weep  and  tremble  with  fright. 

Delirium  presents  other  varieties,  according  to  the  difficulty  of 
its  cure.  If  it  be  light,  it  is  perceived  by  the  patients  themselves, 
who  endeavor  to  correct  their  own  judgment.  If  the  delirium  be 
still  more  apparent,  they  may  still  have  a  desire  to  overcome  it, 
but  the  difficulty  is  greater ;  at  this  time  the  physician  may  cor- 
rect, at  least  for  the  moment,  the  ideas  of  the  patient,  and  obtain 
sensible  answers;  but  the  amendment  is  but  transient,  and  the 
delirium  soon  returns.  When  it  exists  in  a  still  higher  degree, 
nothing  can  suspend  it,  even  momentarily. 

The  duration  of  delirium  is  very  variable.  It  may  last  for  a  few 
minutes  only,  or  continue  for  weeks,  months,  and  even  years. 

After  recovery  from  this  affection,  patients  are  often  unable  to 
recall  anything  that  has  occurred,  not  even  what  appeared  to  have 
been  the  result  of  reflection ;  in  other  cases,  they  have  a  confused 
and  even  clear  recollection  of  what  they  have  experienced. 


SECTION    SEVENTH. 
Symptoms  furnished  by  Sleep. 

The  usual  duration  of  healthy  sleep,  is  nearly  uniform  in  each 
individual ;  it  is  tranquil,  and  refreshes  the  wearied  body.  In  dis- 
ease, it  may  be  prolonged,  diminished,  suspended  or  disturbed, 
and  fails  to  restore  strength. 

It  is  prolonged  in  certain  diseases  accompanied  by  cerebral  con- 
gestion, and  diminished  in  nearly  all  acute  affections.  The  com- 
10* 


114  SYMPTOMS. 

plete  suspension  of  sleep  or  agrypnia*  (insomnia,  pervigilium) 
may  occur  in  a  great  number  of  diseases,  and  from  various  causes, 
such  as  intense  pain,  tinnitus  aurium  and  other  imaginary  sounds, 
difficulty  of  respiration,  frequency  of  cough  and  of  the  excretions, 
restlessness,  mental  agitation,  violent  passions  and  nocturnal  par- 
oxysms. Complete  sleeplessness  is  one  of  the  principal  symptoms 
in  "delirium  tremens ;"  it  is  also  a  marked  symptom  in  typhoid 
fever  ;  for,  in  no  other  acute  disease,  is  it  so  complete  and  constant. 
Sleep  may  be  disturbed  by  night-mare,  dreams,  &c. 

Nightmare  (incubus),^  epkialtes%  oneirodynia,  $  consists  in  a 
feeling  of  suffocation,  which  supervenes  during  sleep,  producing  a 
momentary  but  inexpressible  anguish,  and  causing  the  patient  to 
start  and  awake  in  terror.  The  person,  who  experiences  this 
symptom,  feels  a  sensation  of  great  weight  on  his  chest,  imagines 
that  some  danger  threatens  him,  or  that  he  is  pursued  by  a  phan- 
tom ;  he  makes  ineffectual  efforts  to  escape  from  his  imaginary 
dangers  and  to  cry  for  help,  and  when  he  awakes  is  often  bathed 
in  perspiration.  This  symptom  is  particularly  noticed  in  hypo- 
chondriasis  and  in  cardiac  aneurism,  and  may  sometimes  arise 
from  indigestion. 

Most  of  the  physicians  of  antiquity  paid  great  attention  to 
dreams ;  they  supposed  that  during  sleep,  that  is,  when  the  opera- 
tions of  the  mind  are  undisturbed  by  any  external  sensation,  the 
suffering  of  the  diseased  organ  is  more  distinctly  felt,  producing  in 
the  sensorium  commune  a  disposition  to  certain  dreams.  This 
opinion  is  true,  to  a  certain  extent.  In  diseases  accompanied  with 
great  difficulty  of  respiration,  the  patient  imagines  that  the  dilata- 
tion of  the  chest  is  prevented  by  the  pressure  of  a  considerable 
weight  upon  it.  Galen  mentions  a  man  who  dreamed  for  a  long 
time,  that  one  of  his  legs  had  become  petrified ;  a  short  time  after, 
the  limb  became  paralytic :  the  transient  numbness  which  often 
precedes  paralysis,  sufficiently  explains  this  phenomenon.  It  was 
more  justly  thought  that  ill  nourished  persons  dreamed  of  eating 
certain  articles  of  food.  It  has  been  pretended  that  in  plethora 
and  inflammatory  fevers,  patients  perceive  in  their  dreams,  bodies 
of  a  red  color ;  that  those  suffering  from  dropsy,  dream  of  water, 
streams,  &c. ;  but  these  assertions  do  not  accord  with  observation. 

In  general,  when  occurring  in  disease,  dreams  are  wearisome  and 
painful.  They  may  present  to  the  imagination,  obstacles,  precipices,^ 
fires,  in  short,  any  object  of  embarrassment  and  terror,  sometimes 
causing  the  patient  to  awake  suddenly  in  a  state  of  fright. 

It  is  said  that  the  Egyptians  and  Greeks  placed  their  sick  in  the 
temples,  that  the  gods  might  make  known  to  them,  in  their  dreams, 
the  proper  method  of  their  cure.  Now  that  the  age  of  superstition 
has  passed  away,  no  one  believes  these  salutary  dreams  to  be  the 
inspiration  of  heaven ;  but  respectable  persons  do  not  hesitate  to 

*  " ' Ay$a,  chase  ;  VTTVO?,  sleep. 
•]•  Incubus,  from  incumbere. 
yE(fia^1tg,  from  e<paMonat. 

Ovtioog,  dream  ;  odwy,  pain. 


SYMPTOMS.  115 

accord  to  the  disciples  of  Mesmer,  the  power  of  giving,  with  the 
magical  sleep  produced  by  their  manipulations,  the  knowledge  of 
every  disease  and  its  appropriate  remedies. 

Lastly,  the  sleep  of  invalids  does  not  restore  the  vigor  of  the 
frame ;  and  in  some  affections,  the  paroxysms  of  which  occur  in 
the  night,  the  symptoms  are  of  a  more  aggravated  nature  in  the 
morning  after  a  disturbed  slumber,  than  towards  the  close  of  the 
day,  after  twelve  or  fifteen  hours  of  wakefulness. 

Somnolency  or  drowsiness  (somnolentia)  is  a  state  intermediate- 
between  waking  and  sleeping.  It  is  often  observed  in  typhoid 
fevers  and  in  certain  cerebral  affections. 

Topor  or  cataphora  *  is  a  dull  and  heavy  sleep,  from  which  the 
patient  can  with  difficulty  be  roused  :  this  phenomenon  occurs  in 
the  same  diseases  as  somnolency. 

Coma  f  is  a  still  more  profound  sleep,  from  which  it  is  more 
difficult  to  awaken  the  patient.  Of  this  there  are  two  varieties  : 
1.  The  coma  vigil  (coma  agrypnodes),  which  is  accompanied  by 
delirium,  the  patient  keeping  his  eyes  closed,  excepting  when 
spoken  to,  muttering  to  himself,  and  frequently  changing  his  posi- 
tion ;  2.  coma  somnolentum,  in  which  the  patient  speaks  when 
aroused,  but  remains  silent  and  immovable  in  the  intervals. 
These  two  varieties  are  frequently  observed  in  typhoid  fevers. 

Lethargy  $  (lethargus,  veternus)  is  a  constant  and  still  more 
profound  sleep,  from  which  however  it  is  not  impossible  to  awaken 
the  patient ;  but  when  roused  from  this  state  he  forgets  everything 
he  has  said,  and  appears  unconscious  of  what  he  is  saying, 
speedily  relapsing  into  his  former  condition. 

Lastly,  earns  \\  consists  in  complete  insensibility,  from  which 
nothing  can  arouse  the  patient,  even  for  a  few  instants :  these 
different  symptoms  most  generally  occur  in  the  last  stage  of 
cerebral  diseases,  or  in  cases  of  concussion  or  sudden  compression 
of  the  brain. 

Topor,  coma,  lethargy  and  cams,  are  somewhat  analogous  to 
sleep,  only  differing  as  it  were  in  degree.  It  is  for  this  reason,  that 
they  have  been  considered  in  connection  with  somnolency. 


SECTION    EIGHTH. 

There  are  three  other  symptoms  in  which  the  functions  of  rela- 
tion are  particularly  affected,  and  to  which  we  ought,  perhaps,  to 
allude  before  passing  to  the  consideration  of  the  disturbances  of 
the  internal  functions ;  these  are  lipothymia,  syncope,  and  vertigo. 

Lipothymia  ||  or  lipopsychia,  IT  consists  in  an  almost  entire  sus- 

*  Karaffooa,  fall ;   xaTuysQouat,  I  fall. 
Ktiua,  profound  sleep. 
.Jt,6ij,  oblivion  ;  «oyo$,  idleness. 
,  profound  sleep. 
,  I  leave  ;  Qvuog,  mind. 
,  idem  ;  yvxij,  soul. 


116  SYMPTOMS. 

pension  of  all  the  functions,  with  discoloration  of  the  face  and 
relaxation  of  the  limbs.  Respiration  and  the  circulation  continue, 
but  are  hardly  perceptible.  This  symptom,  when  slight,  is  called 
fainting  (animi  deliquium). 

Syncope  *  presents  the  same  phenomena,  together  with  a  more 
complete  suspension  of  the  respiration  and  circulation.  Syncope, 
lipothymia  and  fainting  may  occur  in  consequence  of  acute  pain, 
or  lively  emotions,  copious  bloodletting  or  abundant  and  painful 
stools.  The  ingress  of  air  into  the  circulatory  system,  during  a 
surgical  operation,  may  occasion  fatal  syncope.  This  symptom  is 
not  unfrequently  observed  at  the  commencement  of  eruptive  fevers, 
in  the  course  of  pestilential  fevers,  in  gangrenous  affections  and 
cases  of  profuse  suppuration.  The  periodical  return  of  this  affec- 
tion constitutes  one  of  the  severest  forms  of  malignant  intermittent 
fever.  It  is  not  uncommon  at  an  advanced  period  of  chronic 
diseases,  and  in  persons  very  much  reduced  in  strength,  it  often 
precedes  sudden  death. 

Vertigo  (vertigines)  produces  in  the  patient  a  sensation  of  turn- 
ing, or  gives  to  external  objects  the  appearance  of  rotation  around 
him ;  this  sensation  is  almost  always  accompanied  by  palpitation 
of  the  heart  and  a  feeling  of  faintness.  Vertigo  tenebricosa  f  (capitis 
omnubilatio)  is  the  term  applied  to  that  variety  in  which  the  sight 
becomes  obscured  as  if  by  a  cloud.  This  affection  occurs  at  the 
commencement  of  many  severe  acute  diseases,  often  returning 
during  their  course,  particularly  if  the  patient  execute  any  move- 
ment, as  in  attempting  to  sit  down  or  rise  up.  Vertigo,  accompa- 
nied with  a  sudden  loss  of  consciousness  and  soon  followed  by 
headache  with  a  feeling  of  debility  and  heaviness,  constitutes 
a  form  of  epilepsy,  apparently  lighter,  but  more  frequently 
followed  by  mental  alienation,  than  the  more  common  form  of 
that  disease. 


ARTICLE    SECOND. 
Symptoms  furnished  by  the  Internal  or  Assimilative  Functions. 

WE  have  now  considered  the  principal  derangements  presented, 
in  disease,  by  the  functions  which  serve  to  establish  the  relations 
of  man  with  external  objects.  We  shall  next  proceed  to  the 
examination  of  those  furnished  by  the  internal  functions,  diges- 
tion, respiration,  the  circulation,  calorification  and  the  secretions. 

*  Svyxonrtn,  I  fall  down, 
f  Verier e,  to  turn. 


SYMPTOMS.  117 

SECTION  FIRST. 
Symptoms  furnished  ly  Digestion. 

In  health,  the  appetite  returns  at  regular  intervals,  its  gratifica- 
tion is  attended  with  pleasure,  the  thirst  is  moderate,  the  stomachic 
digestion  effected  with  freedom,  without  eructation  or  oppression, 
the  faecal  matters  are  of  proper  consistence,  in  quantity  propor- 
tionate to  the  food,  and  their  excretion  is  accomplished  without 
pain.  Each  of  the  organs  which  contribute  to  the  performance  of 
this  function  presents  a  healthy  appearance ;  the  teeth  are  white, 
smooth,  and  firmly  implanted  in  their  alveoli ;  the  gums  are  firm, 
smooth  and  of  a  pale  red  color ;  the  inner  surface  of  the  mouth  is 
moist  and  of  a  reddish  hue ;  the  abdomen,  in  which  is  contained 
most  of  the  digestive  apparatus,  is  of  its  natural  size  and  sup- 
pleness. 

Under  the  influence  of  disease,  every  act  of  digestion,  and  all 
the  organs  which  contribute  to  its  performance,  present  more  or 
less  marked  derangements,  which  we  shall  consider  in  the  order  of 
their  succession. 

A.  Hunger,  the  appetite  or  the  desire  of  taking  food  is  seldom 
increased  in  disease :  this  symptom  is,  however,  sometimes  ob- 
served in  mania  and  verminous  affections.  In  some  cases,  hunger 
is  so  urgent,  that  unless  it  is  satisfied,  fainting  ensues ;  this  is 
called  boulimus,  *  a  phenomenon  of  common  occurrence  in  hy- 
steria, but  still  more  frequently  observed  during  pregnancy.  In 
other  cases,  the  patient  eats  with  voracity  until  the  stomach 
relieves  itself  by  vomiting;  this  is  called  (fames  canind)-\.  In 
other  diseases,  the  food  which  is  devoured  with  greediness,  is 
almost  as  soon  expelled  by  the  anus  ;  this  has  been  called  (fames 
lupina)  J .  The  two  latter  symptoms  are  of  rare  occurrence. 

Diminution  of  appetite  (dysorexia)^  accompanies  nearly  all  the 
acute  and  chronic  diseases  of  moderate  intensity. 

In  those  of  greater  severity,  and  particularly  in  acute  diseases 
attended  with  violent  febrile  symptoms,  the  appetite  is  entirely 
lost ;  this  is  termed  inappetentia  or  anorexia  || .  An  entire  and  pro- 
longed absence  of  appetite,  and  progressive  emaciation,  are  some- 
times the  two  only  symptoms  indicative,  in  adult  age,  of  chronic 
disease  of  the  stomach. 

In  certain  chronic  diseases,  the  appetite  is  unequal  to  a  remark- 
able degree;  the  patient  being  one  day  affected  with  insatiable 
hunger,  and  the  next,  suffering  from  complete  anorexia,  this  alter- 
nation sometimes  occurring  the  same  day. 

*  Bov,  augmentative  particle  ;  Jit/*og,  hunger. 

t  Canis,  dog. 

t  From  lupus,  wolf. 

§  Jvg,  with  difficulty;  ooj£«s,  appetite. 

||  A  privative,  o^eitf,  appetite. 


118  .          SYMPTOMS. 

In  others,  the  desire  of  food  is  not  real ;  this  is  commonly  called 
a  false  appetite.  In  these  cases  no  sooner  does  the  patient  taste 
his  food,  than  he  feels  already  satiated ;  this  is  particularly  ob- 
served in  phthisis. 

The  appetite  may  become  depraved  in  two  ways.  1.  There  is 
disgust  (cibi  fastidium.  apositia)  *  or  aversion  for  food.  Disgust 
should  not  be  confounded  with  anorexia  :  the  latter  is  only  an  entire 
absence  of  appetite,  while  the  former  consists  in  real  repugnance  for 
food.  This  repugnance  is  sometimes  so  great,  that  the  sight  of  food, 
or  the  mention  of  its  name,  is  alone  sufficient  to  produce  nausea. 
It  is  of  rare  occurrence  except  in  grave  diseases,  while  anorexia  ac- 
companies the  slightest  disorder.  2.  The  other  variety  of  depraved 
appetite,  is  that  in  which  an  almost  general  loathing  is  combined 
with  a  desire  for  some  particular  article  of  food ;  if  this  substance 
be  eatable,  the  symptom  is  called  malacia  f  ;  if,  on  the  contrary, 
it  be  not  eatable  or  noxious,  it  constitutes  picaj..'  Both  these 
symptoms  frequently  occur  in  hysteria  and  mania,  and  often  in 
pregnancy.  In  connection  with  these  affections  of  the  appetite, 
may  be  mentioned  the  sensations  of  bitterness,  clamminess,  dryness 
of  the  mouth,  experienced  in  many  diseases,  and  particularly  in 
febrile  affections  and  gastric  disorder. 

B.  The  thirst  is  increased  in  most  acute  diseases,  and  particu- 
larly in  diabetes.     It  is  rarely  diminished,  and  more  rarely  abol- 
ished in  patients  whose  intellectual  faculties  remain  unimpaired. 
In  the  derangement  of  the  ideas  and  sensations,  accompanying 
delirium,  the  absence  of  thirst  and  refusal  to  drink  exist  toge'ther 
with  other  phenomena.  f 

C.  The  examination  of  the  different  parts  of  the  mouth,  fur- 
nishes us  with  important  symptoms.     We  have  before  described 
the  morbid  appearances  presented  by  the  lips,  and  now  proceed  to 
consider    those  furnished  by  the  teeth,    gums,  tongue,    internal 
surface  of  the  cheeks  and  back  part  of  the  mouth. 

The  symptoms  furnished  by  the  teeth,  may  depend  upon  some 
affection  of  these  organs  themselves,  or  be  connected  with  the 
existence  of  other  diseases. 

In  certain  acute  affections  in  which  the  secretion  of  the  mucous 
membranes  acquires  a  remarkable  degree  of  acidity,  the  teeth 
become  the  seat  of  a  peculiar  sensation,  in  which  they  are  said  to 
be  set  on  edge,  (dentium  hebetudo)  ;  this  phenomenon  is  sometimes 
observed  in  continued  fevers. 

The  teeth  of  the  lower,  in  gliding  upon  those  of  the  upper  jaw, 
produce  a  grinding  sound  (stridor  dentium),  a  symptom  which 
accompanies  some  acute  cerebral  affections ;  in  other  cases,  as  in 
the  cold  stage  of  intermittent  fever,  there  is  what  is  termed  chat- 

*  *  Ana,  OITIOV,  aversion  for  food. 

f  Malaxia,  softness. 

|  Pica  or  Kioaa,  magpie,  its  opposite  colors  form  a  contrast  analogous  to  that 
afforded  by  the  depraved,  when  compared  with  the  natural,  appetite. 


SYMPTOMS.  119 

tering  of  the  teeth  (dcntrum  collisus,  crepitus),  in  which  the  teeth 
strike  rapidly  against  each  other.  According  to  some  authors* 
the  force  with  which  the  teeth  sometimes  come  together  is  sufi- 
cient  to  fracture  them.  In  scorbutic  affections,  mercurial  stom- 
atitis, and  simple  chronic  engorgement  of  the  gums,  the  teeth 
sometimes  become  loose  and  even  entirely  detached  from  their 
sockets.  Lastly,  in  chronic  diseases  they  appear  elongated,  owing 
to  the  shrinking  of  the  gums  which  is  coincident  with  the  general 
emaciation. 

A  thorough  examination  of  the  teeth  is  important,  as  many 
affections  of  the  mouth  are  often  produced  and  kept  up  by  a 
decayed  or  falsely  directed  tooth.  Among  others,  may  be  men- 
tioned caries  and  necrosis  of  the  maxillary  bones,  odontalgia, 
fistula  of  the  face,  and  enlargement  of  the  lymphatic  glands  of  the 
neck,  which  may  be  owing  to  no  other  cause  than  dental  caries. 
Apthae,  ulceration  of  the  mucous  membrane  of  the  mouth,  and 
particularly  of  the  tongue,  with  hardened  and  inverted  edges  and 
a  greyish  and  fungous  surface,  are  not  unfrequently  caused  by 
the  inequalities  of  a  broken  or  wrongly  directed  tooth. 

The  gums  present  some  important  changes :  they  are  swollen 
in  mercurial  salivation  and  scurvy ;  in  the  former  case,  they  are 
red,  in  the  latter,  blackish  and  flabby;  in  both  cases,  they  exhale 
an  odor  sui  generis.  It  has  been  remarked  by  M.  Rostan,  at  the 
Salpetriere,  that  after  loss  of  the  teeth,  and  when  the  gums  had 
become  callous  from  mastication,  swelling  did  not  take  place  in 
them  to  the  same  degree  as  before ;  and  if  the  teeth  of  one  jaw  be 
lost,  while  those  of  the  opposite  remain,  the  gums  of  the  latter 
become  swollen,  while  those  of  the  former  retain  their  usual 
appearance.  *  The  gums  become  pale  in  diseases  of  debility,  and 
particularly  in  passive  dropsies ;  they  are  of  a  redish  brown  color 
in  some  anginose  affections. 

The  state  of  the  tongue,  in  disease,  has  always,  and  very  justly, 
claimed  the  attention  of  physicians.  The  importance  of  the  signs 
which  it  furnishes,  has,  it  is  true,  been  much  exaggerated ;  but  if 
they  be  reduced  to  their  true  value,  the  tongue  furnishes  semiology 
with  numerous  interesting  facts. 

In  health,  the  tongue  is  generally  of  a  red  color,  smooth  surface, 
slightly  granulated  towards  its  apex,  and  covered  with  pointed  vil- 
losities  and  hemispherical  glandules  towards  its  base ;  its  surface  is 
moist,  it  is  free  in  its  movements,  the  object  of  which  is  principally 
in  speaking,  mastication  and  deglutition.  In  chronic  diseases, 
even  in  those  of  the  stomach,  the  tongue  often  remains  in  its 
natural  condition ;  this  is  sometimes  the  case  in  acute  diseases ; 
and  this  phenomenon  which  is  without  value  in  the  first,  is  gen- 
erally a  favorable  sign  in  the  latter  case,  provided  the  other 
symptoms  be  not  unfavorable.  Under  the  influence  of  disease  the 
tongue  presents  changes  in  relation  to  its  volume,  form,  movements, 

*  De  recondita  Febr.  int.  turn,  remit.  ;  Natura,  p.  43. 
f  Cours  de  Mcd.  Clin.,  t.  1,  p.  250. 


120  SYMPTOMS. 

color,  moisture,  coats,  eruptions  of  which  it  is  sometimes  the  seat, 
and  lastly,  its  temperature  and  tactile  and  gustatory  sensibility. 

The  volume  of  the  tongue  becomes  rarely  increased  in  affections 
of  which  it  is  not  the  special  seat.  In  some  acute  diseases,  how- 
ever, this  organ  becomes  so  voluminous  as  to  fill  the  whole  mouth, 
preserving  the  impression  of  the  teeth  upon  its  surface.  This 
phenomenon  should  lead  the  physician  to  suspect  the  influence  of 
some  mercurial  preparation.  At  other  times  swelling  of  the  tongue 
is  in  consequence  of  violent  angina ;  it  is  in  these  cases  owing  to 
stagnation  of  blood  in  this  organ  ;  it  is  always  a  symptom  indica- 
tive of  great  danger. 

Shrinking  of  the  tongue  is  a  frequent  symptom  in  typhus  and 
other  grave  fevers ;  it  is  at  the  same  time  in  a  state  of  dryness  and 
tremor,  conditions  equally  unfavorable. 

In  marasmus,  the  tongue  rarely  becomes  diminished  in  size.  But 
a  single  example  of  partial  atrophy  of  this  organ  has  been  recorded. 
This  case,  mentioned  in  the  forty-fourth  bulletin  of  the  anatomical 
society,  relates  to  a  man,  one  half  of  whose  tongue  was  pale,  dis- 
colored, wrinkled  and  atrophied  without  any  change  in  its  sensi- 
bility. The  patient  died  with  symptoms  of  paralysis,  and  the 
autopsy  revealed  an  hydatid  cyst  in  the  left  occipital  fossa  which 
compressed  the  glosso  pharyngeal  nerve. 

The  form  of  the  tongue,  in  disease,  presents  remarkable  varie- 
ties ;  it  becomes  in  some  cases,  conical,  in  others,  pointed.  The 
latter  modification  has  been  recently  pointed  out  as  peculiar  to 
inflammation  of  the  stomach,  but  this  is  not  in  accordance  with 
the  results  of  experience.  These  peculiarities  in  the  form  of  the 
tongue  do  not  indicate  with  certainty  the  nature  and  seat,  more 
than  the  danger  of  the  disease.  The  pointed  form  depends  solely 
upon  the  mode  of  contraction  of  the  intrinsic  muscles  of  the  organ. 

Difficulty  in  the  motions  of  the  tongue  either  in  the  articulation 
of  sounds,  or  the  act  of  protruding  it,  is  a  frequent  symptom  in  the 
course  of  grave  fevers ;  this  condition  is  always  an  unfavorable 
sign. 

In  some  cases  of  hemiplegia,  when  the  tongue  is  thrust  out  of 
the  mouth,  its  point  appears  drawn  away  from  the  paralyzed  side  ; 
it  has  been  attempted  to  explain  this  phenomenon  by  supposing 
paralysis  of  the  genio-glossus  and  stylo-glossus  muscles.  But  this 
deviation  is  often  but  apparent ;  its  point  being  nearer  one  commis- 
sure than  the  other,  the  tongue  is  supposed  to  deviate  from  its  right 
direction ;  but  it  is  the  commissure,  not  the  tongue  which  is  affected. 

Paralysis  of  the  tongue  whether  it  consist  in  the  deviation  of  its 
point,  or  is  apparent  from  the  difficulty  in  pronunciation  and  mas- 
tication, constitutes,  in  all  cases,  an  important  diagnostic  sign,  as 
it  is  an  almost  certain  index  of  a  cerebral  lesion. 

The  color  of  the  tongue  may  be  altered  either  immediately  and 
by  a  change  in  the  color  of  the  organ  itself,  or  mediately,  by  the 
coat  with  which  it  becomes  covered.  Paleness  and  discoloration 
of  the  tongue  rarely  occur  except  in  cases  of  chlorosis  and  anemia. 


SYMPTOMS.  121 

In  organic  affections  of  the  heart  it  partakes  of  the  lividity  of  the 
neighboring  parts. 

The  coats  which  form  upon  the  tongue  are  generally  confined  to 
its  superior  surface,  and  are  of  various  colors.  Those  most  com- 
monly observed  are  white,  yellow,  greenish,  brownish  and  black. 
These  coats  may  be  thick  or  thin,  tenacious  or  easily  removed,  dry 
or  moist,  of  uniform  or  unequal  extent,  disposed  in  patches,  or 
presenting  undulations  analogous  to  those  observed  on  geographical 
charts.  These  coats,  it  would  appear  from  the  chemical  analysis 
of  Vauquelin,  Laugier  and  M.  Denis,  have  the  same  origin  with 
the  dental  tartar.  According  to  others,  they  are  formed  by  the 
drying  of  the  salivary  fluid. 

Whenever  the  surface  of  the  tongue  presents  one  of  the  above- 
mentioned  coats,  some  morbid  condition  generally  exists.  I  say 
generally,  for  there  are  many  persons  in  whom  abstinence  alone 
produces  a  whitish  coat ;  and  in  others,  this  is  constant  at  all  times 
in  the  day,  although  their  health,  in  other  respects,  is  perfectly 
good.  There  are  others,  as  we  have  before  mentioned,  who,  being 
obliged  to  sleep  with  the  mouth  open  on  account  of  the  natural 
straitness  of  the  nasal  fossae,  awake  with  a  dry  and  often  yellowish 
tongue.  With  these  exceptions,  a  coated  tongue  almost  always  in- 
dicates disease.  There  are  others  in  whom  the  superior  surface  of 
the  tongue  receives  and  preserves  the  color  of  the  food  and  drinks 
taken,  becoming  of  a  dark  livid  hue  by  the  contact  of  red  wine, 
and  colored  drinks  and  food  generally,  as  syrups  prepared  from 
red  fruit,  chocolate,  &c.  But  this  aptitude  of  the  tongue  to  receive 
and  retain  coloring  matters  rarely  occurs  except  in  disease,  when 
the  villosities  of  the  organ  become  impregnated  with  the  colors  with 
which  they  are  brought  in  contact. 

Are  we  to  believe  with  the  physicians  of  antiquity  that  the  state 
of  the  tongue  is  a  true  index  to  that  of  the  stomach  ?  Is  it  true 
that  a  yellowish,  or  greenish  coat  upon  the  tongue,  is  indicative  of 
bile  in  the  stomach  ;  that  a  blackish  coat  should  cause  us  to  fear 
the  presence  of  putrid  matters  in  the  digestive  passages  ?  Lastly, 
are  we  to  suppose  with  Broussais,  that  redness  of  the  tongue  is  a 
pathognomonic  sign  of  gastritis  ?  Accurate  observation  has  long 
since  shown  the  entire  inconsistency  of  these  various  assertions 
with  facts.  Thus,  it  was  found  by  M.  Louis,  in  analyzing  a  great 
number  of  cases,  in  his  researches  on  phthisis,  that  redness  of  the 
tongue  existed  in  an  equal  number  of  patients  in  whom  the  stomach 
was  found  healthy,  with  those  in  whom  this  organ  presented  a 
grave  lesion.  The  researches  of  the  same  author  upon  typhoid 
fever  led  to  nearly  the  same  results  as  to  the  state  of  tongue  in  the 
course  of  that  disease.  Indeed,  whatever  aspect  this  organ  pre- 
sented, no  correspondence  between  it  and  that  of  the  stomach 
could  be  detected,  being  the  same  in  those  cases  in  which  there 
was  a  grave  lesion  of  the  mucous  membrane  of  the  stomach,  as  in 
those  which  presented  a  healthy  appearance.  According  to  the 
skilful  observer  whom  we  have  just  cited,  the  blackish  color, 
11 


122  SYMPTOMS. 

roughness  and  cracked  appearance  of  the  tongue,  are  chiefly  owing 
to  the  intensity  of  the  febrile  action,  whatever  be  its  cause. 

The  tongue  may  preserve  its  natural  moisture  and  supple- 
ness, although  its  surface  at  the  same  time  be  covered  by  white, 
yellow,  or  greenish  coats;  but  is  constantly  dry,  or  clammy, 
when  loaded  with  a  blackish,  or  brownish  fur.  Dryness  of  this 
organ  is  more  or  less  considerable  ;  it  may  be  also  partial  or  gen- 
eral. When  existing  in  a  slight  degree,  it  is  only  apparent  from 
the  sensation  experienced  by  the  patient,  and  a  kind  of  noise  which 
accompanies  the  motions  of  the  tongue,  and  which  is  owing  to  the 
detachment  of  this  organ  from  the  parts  of  the  mouth,  particularly 
the  mucous  membrane  of  the  palate,  to  which  it  was  adherent. 
The  finger  placed  upon  the  tongue  and  drawn  slowly  over  its  sur- 
face, seems  to  be  gently  retained  by  a  viscid  substance.  This  is 
rather  a  simple  diminution  in  the  degree  of  moisture,  than  a  state 
of  dryness.  In  a  more  advanced  stage,  the  coating  is  more  viscid  ; 
the  tongue  in  this  case  is  said  to  be  pitchy  (poisseuse).  Lastly, 
when  this  phenomenon  is  still  more  marked,  the  organ  is  com- 
pletely deprived  of  moisture.  Dryness  of  the  tongue  sometimes 
occurs  only  during  sleep,  disappearing  when  the  patient  awakes, 
or  after  he  has  taken  liquid  food  ;  at  other  times,  it  continues  dur- 
ing a  part  of  the  day,  or  for  several  days.  In  the  latter  cases,  it 
becomes  also  smooth,  shining  and  red,  or  rough,  wrinkled  and 
black.  This  condition  of  the  tongue,  in  acute  diseases,  is  generally 
indicative  of  danger.  If  it  occur  in  the  course  of  a  chronic  disease 
it  almost  always  announces  approaching  death. 

A  phenomenon  of  great  importance  in  semeiology,  is  the  ex- 
istence of  whitish  and  yellow  patches  or  pimples,  often  confluent, 
sometimes  disposed  in  the  form  of  a  pultaceous  coat,  and  some- 
times in  thin  and  reticulated,  or  thick  and  opaque  membranes, 
which  are  alternately  detached  and  reproduced,  generally  appear- 
ing simultaneously  or  successively  upon  the  upper  surface  and 
sides  of  the  tongue,  the  internal  surface  of  the  cheeks  and  the 
velum  pendulum  palati  and  its  pillars.  The  appearance  of  these 
patches  is  of  little  importance  as  a  diagnostic  sign,  for  it  belongs  to 
no  particular  disease,  but  is  of  great  utility  in  prognosis.  In 
chronic  diseases,  it  is  an  inauspicious  omen,  particularly  if  the 
eruption  last  beyond  a  certain  number  of  days,  or  is  reproduced 
many  times.  In  acute  affections,  though  not  so  grave  a  sign,  it 
may  with  other  symptoms  lead  us  to  fear  the  result.  The  same 
eruption  occurs  temporarily,  particularly  in  old  persons,  without 
any  derangement  of  the  health  ;  its  semeiotic  value  is  not  the  same 
in  these  cases  as  when  occurring  in  the  course  of  a  grave  disease. 

The  superior  surface  of  the  tongue  sometimes  presents,  particu- 
larly towards  its  apex,  very  small  red  spots,  considered  by  M. 
Roux  as  a  certain  sign  of  the  existence  of  syphilitic  virus.  We 
only  call  the  attention  of  observers  to  this  sign,  the  value  of  which 
we  have  not  as  yet  been  able  to  appreciate.  The  grayish  ulcera- 
tions  which  sometimes  appear  upon  the  edges  and  point  of  the 
tongue,  and  which  should  not  be  confounded  with  those  occasion- 


SYMPTOMS.  123 

ally  produced  by  inequalities  of  the  teeth,  are  of  syphilitic  origin, 
as  their  appearance  indicates.  The  same  may  be  said  of  those 
flat,  hard,  circumscribed  tumors  of  a  red  or  grayish  color,  from 
two  to  five  lines  in  breadth,  which  appear  upon  this  organ,  and 
arise  from  the  same  cause. 

Lastly,  the  transverse  and  often  irregular  cicatrices  which  the 
surface  of  the  tongue  sometimes  presents,  should  lead  us  to  suspect 
epilepsy,  the  existence  of  which  is  often  concealed  from  the  phy- 
sician. This  may,  consequently,  become  in  some  cases  a  highly 
important  sign. 

A  change  in  the  temperature  of  the  tongue  becomes  rarely  suffi- 
cient to  claim  the  attention.  In  the  last  stages  of  acute  or  chronic 
disease,  it  may  become  very  cold,  a  sign  indicative  of  approaching 
death.  In  cholera,  the  coldness  of  the  tongue  was  an  almost 
constant  symptom,  and  in  many  cases  in  which  it  occurred, 
the  patients  recovered.  It  is  perhaps  unnecessary  to  add  that  this 
phenomenon  would  be  without  value,  if  the  patient  had  just 
before  taken  ice  or  cold  drinks. 

In  the  course  of  certain  cerebral  affections,  and  in  those  diseases 
which  affect  the  nerves  distributed  to  the  tongue,  the  tactile  or 
gastatory  sensibility  of  this  organ  may  become  diminished.  From 
the  experiments  of  physiologists,  confirmed  by  pathological  obser- 
vations, it  would  appear  that  paralysis  of  sensation  is  the  result 
of  a  material  lesion  of  the  lingual  nerve. 

The  parts  which  form  the  posterior  part  of  the  mouth,  are  also 
the  seat  of  symptoms  appreciable  to  the  sight ;  they  may  become 
swollen,  red,  dry,  and  ulcerated.  The  velum  palati  may  be  de- 
pressed by  an  abscess  in  its  substance,  or  by  a  tumor  developed  in 
the  nasal  fossae ;  it  may  be  partially  destroyed  or  perforated  by 
an  ulcer.  It  has  been  observed  to  deviate  to  the  right  or  left  in 
some  cases  of  facial  paralysis.  The  uvula  may  deviate  from  the 
median  line,  become  pendent,  infiltrated,  or  entirely  destroyed. 
The  brown  or  blackish  coat  sometimes  observed  upon  other  parts 
of  the  mouth,  extends  also  to  this ;  apthas  often  manifest  them- 
selves here ;  and  it  is  generally  upon  the  velum,  sometimes  upon 
the  tongue  and  inner  surface  of  the  cheeks,  that  those  whitish 
patches  which  occur  in  the  last  period  of  chronic  diseases,  and 
which  announce  a  fatal  termination,  appear. 

D.  Mastication  is  often  difficult  and  painful  in  disease.     Odon- 
talgia,   swelling  of   the  face,  dental  caries,  rheumatism  of  the 
ternpero-maxillary  articulation,  fracture  of  the  maxillary  bones, 
dislocation  of  the  lower  jaw,  are  all  diseases  which  may  render 
mastication  impossible.     To  these  may  be  added,  disease  of  the 
gums,  tongue,  and  cheeks,  the  integrity  of  which  is  necessary  to 
performance  of  this  function. 

E.  Deglutition  appears  to  be  more  rapidly  performed  in  some 
acute  affections,   the  patients  swallowing  the  contents  of  a  cup 
presented  to  them  almost  instantly ;  it  is  slower  and  accomplished 


124  SYMPTOMS. 

with  difficulty  in  nearly  all  the  diseases  of  the  pharynx  and 
oesophagus,  as  angina,  paralysis,  and  schirrus ;  the  existence  of  a 
neighboring  tumor  compressing  the  pharynx  or  oesophagus,  the 
presence  of  a  foreign  body  in  these  passages,  hysteria,  grave 
fevers,  diseases  of  the  brain  and  upper  part  of  the  spinal  marrow, 
are  all  affections  in  which  deglutition  may  become  difficult  Diffi- 
culty of  deglutition  has  been  designated  dysphagia.*  It  presents 
many  remarkable  varieties.  Some  patients  can  swallow  liquids, 
but  are  unable  to  swallow  solid  substances ;  this  is  often  observed 
in  angina ;  in  other  diseases,  as  paralysis,  the  deglutition  of  solids 
can  be  accomplished,  while  that  of  liquids  is  impossible.  These 
opposite  phenomena  have  been  satisfactorily  explained ;  in  angina, 
the  inflamed  mucous  membrane  cannot  bear  the  contact  of  a  solid 
body,  while  in  paralysis  the  muscles  of  the  pharynx  being  en- 
feebled in  their  action,  cannot  contract  with  sufficient  force,  to 
conduct  liquids  from  the  mouth  to  the  ossophagus,  but  can  act 
upon  a  more  voluminous  and  consistent  body  as  the  alimentary 
bolus. 

Morgagni^  according  to  a  dissertation  of  Spies  on  deglutition, 
speaks  of  a  singular  variety  of  dysphagia  observed  in  an  old  man  : 
this  person  was  able  to  swallow  all  kinds  of  food,  but  the  last 
alimentary  bolus  remained  in  the  oesophagus  till  the  next  meal, 
unless  rejected  by  the  mouth,  during  the  interval,  in  the  effort  of 
coughing.  In  the  explanation  of  this  phenomenon,  Morgagni 
supposed  that  the  action  of  the  muscles  of  the  oesophagus  alone, 
was  insufficient  to  force  the  bolus  from  the  pharynx  into  the 
stomach,  which  could  only  be  accomplished  by  the  weight  of 
another  bolus,  together  with  the  contraction  of  the  oesophagus. 
This  disorder  of  deglutition  he  very  ingeniously  compared  to  a 
similar  lesion  presented  by  the  excretion  of  urine  in  old  persons ; 
the  bladder  being  incapable  of  emptying  itself  completely  of  the 
urine  it  contains. 

Deglutition  may  become  impossible  from  causes  analogous  to 
those  which  render  it  difficult. 

The  absolute  impossibility  of  swallowing  liquids,  together  with 
a  horror  for  every  kind  of  drink,  constitutes  hydrophobia^  a 
symptom  which  generally  occurs  in  rabies  and  sometimes  in 
typhoid  affections  and  hysteria.  When  this  symptom  exists,  the 
sight  of  water,  or  of  any  shining  body,  often  occasions  convulsions 
almost  tetanic  in  their  nature. 

Deglutition  may  be  depraved  in  two  ways :  1,  there  may  be 
continual  efforts  to  swallow,  with  successive  action  of  the  muscles 
destined  to  this  purpose,  while  the  mouth  remains  empty ;  this  has 
been  observed  in  elongation  of  the  uvula  and  some  nervous  affec- 
tions ;  2,  food  carried  into  the  posterior  part  of  the  mouth,  instead 
of  being  transmitted  directly  into  the  oesophagus,  may  pass  either 
into  the  nasal  fossae,  as  is  the  case  in  diseases  of  the  velum,  or 

*  Jvc,  with  difficulty;  (payo>,  I  eat. 

t  De  Sedibus  et  Cuusis  mort.,  epist.  1,  art.  14. 

J  rK(%o(jo|*ia,  from  vvtiwq,  water  ;  (popoc,  fear. 


SYMPTOMS.  125 

into  the  larynx,  a  much  rarer  and  more  serious  phenomenon,  and 
which  can  only  take  place  in  cases  of  ulceration  of  the  opening 
of  the  larynx  (Archives,  Septembre  1839,  Memoire  de  M.  Earth), 
or  in  the  agony  and  in  patients  who  swallow  involuntarily.  It 
is  hardly  necessary  to  add  that  in  cases  of  ulceration,  rupture,  or 
wound  of  the  oesophagus,  the  food  may  escape  from  it,  and  pass 
into  the  cavity  of  the  chest. 

There  is  another  derangement  of  deglutition,  in  which  fluids 
poured  into  the  mouth,  are  carried  by  their  weight  alone  through 
the  oesophagus,  producing  a  sound  by  their  fall  into  the  stomach  as 
if  poured  through  an  inert  tube.  This  symptom  occurs  only  in 
the  moribund. 

F.  Stomachal  digestion  becomes  rarely  more  active  under  the 
influence  of  diseases ;  in  maniacs,  however,  the  action  of  the 
stomach  appears  sometimes  greater  than  in  health ;  but  in  most 
diseases  it  is  enfeebled,  as  is  apparent  from  the  sense  of  weight  in 
the  epigastrium,  and  the  general  uneasiness  and  aggravation  of  all 
the  symptoms  after  a  meal.  Patients  who  take  no  food  often 
experience  various  phenomena  which  indicate  functional  disturb- 
ance of  the  stomach;  as  nausea,  retching,  regurgitations,  vomiting 
and  epigastric  pain. 

1.  Nausea    consists    in    a    simple    desire    to    vomit,   retching 
(vomituritio)  in  ineffectual  efforts  to  accomplish  this  object.     Both 
these  symptoms  accompany  many  diseases,  and  particularly  those 
of  the  digestive  organs. 

2.  Under  the  term  subsultus  prczcordiorum,  a  peculiar  phenom- 
enon  has   been   also   described,    which   consists  in  a  convulsive 
action  of  the  stomach  which  prevents  the  admission  of  more  food, 
and  the  expulsion  of  what  it  already  contains,  notwithstanding 
the  efforts  of  the  patient. 

3.  Regurgitation  (regurgitatio)    is  the  act  by   which  certain 
gaseous  or  liquid,  rarely  solid,  substances,  rise  from  the  stomach  or 
oesophagus  into  the  mouth,   unaccompanied  by  the  efforts  peculiar 
to  vomiting.     Renvois  is  the  term  applied  to  matters  thus  rejected. 
Regurgitation  may  be  complete  or  incomplete,  in  the  one  case,  the 
substances  rising  into  the  pharynx  and  mouth,  in  the  other,  being 
arrested  in  some  part  of  the  oesophagus  and  again  passing  into 
the  stomach ;    it  may  be  rare  or  frequent ;  and  lastly,  it  may 
afford  relief  to  the  patient,  or  cause  increased  suffering. 

The  renvois  or  substances  rejected  by  regurgitation  may  be 
gaseous,  liquid,  or  solid :  the  gases  or  eructations  (ructus)  ma'y  be 
inodorous,  as  is  observed  in  nervous  diseases  ;  they  may  exhale 
the  odor  of  sulphuretted  hydrogen  (decayed  eggs),  that  of  sub- 
stances last  eaten,  or  be  slightly  rancid  (nictus  nidorosi)*  as  in 

*  The  sense  of  the  word  nidorous  is  not  well  defined  ;  it  indicates,  in  its  ety- 
mological acceptation,  the  odor  of  animal  matters  in  a  state  of  combustion  ;  but 
most  authors  have  employed  it  to  express  a  repulsive  odor. 
11* 


126  SYMPTOMS. 

indigestion.  The  liquids  which  rise  into  the  mouth  are  sometimes 
insipid;  they  are  sour  in  carcinoma  of  the  stomach,  bitter  in 
bilious  disorders,  and  sharp  and  burning  in  pyrosis.  Solid 
matters  rejected  by  regurgitation  almost  always  consist  of  the 
remains  of  the  preceding  digestion,  which  have  not  undergone 
the  necessary  elaboration.  The  renvois  are  generally  gaseous  or 
liquid  ;  in  some  cases  regurgitation  of  both  takes  place  simulta- 
neously. Solid  matters  are  almost  always  accompanied  by  a  cer- 
tain quantity  of  liquid. 

In  connection  with  this  phenomenon  may  be  mentioned,  rumi- 
nation or  merycismus*  which  consists  in  masticating,  a  second 
time,  food  carried  into  the  mouth  by  a  sort  of  antiperistaltic  con- 
traction of  the  stomach  and  oesophagus.  This  affection,  upon 
which  Dr.  Gintrac  of  Bordeaux  has  written  an  interesting  treatise, 
is,  in  most  cases,  congenital.  It  however  sometimes  occurs  acci- 
dentally in  old  persons  affected  with  cerebral  disease,  in  whom 
there  is  insufficient  mastication  together  with  too  great  ingestion 
of  food  ;  in  these  cases,  the  food  rising  into  the  mouth  undergoes 
a  second  mastication,  without  occasioning  the  person  trouble  or 
inconvenience. 

4.  Vomiting  (vomitus)  is  the  act  by  which  substances  contained 
in  the  stomach  are  ejected  by  the  mouth,  with  effort,  and  in  cer- 
tain quantities. 

Vomiting  takes  place  under  various  circumstances,  and  may 
depend  upon  an  affection  of  the  stomach  or  other  parts  of  the  econ- 
omy more  or  less  remote.  It  has  occurred  in  gastric  derangement, 
simple  indigestion,  gastrites,  softening  and  cancer  of  the  stomach. 
The  affections  of  the  various  parts  contained  within  the  abdom- 
inal cavity,  in  which  vomiting  is  liable  to  occur,  are  inflammations 
and  organic  lesions  of  the  peritoneum,  intestines,  liver,  kidneys, 
bladder,  cellular  tissue  of  the  illiac  fossse,  and  uterus,  intestinal 
and  epiploic  hernia,  occlusion  of  the  intestines  whatever  be  its 
cause,  hepatic  nephritic  and  saturnine  colic,  and  pregnancy.  The 
thoracic  phlegmasise,  and  particularly  acute  bronchitis,  whooping 
cough  and  tubercles,  produce,  in  the  paroxysms  of  coughing, 
obstinate  vomiting  ;  some  cases  of  tonsillitis  and  pharyngitis,  and 
simple  oedema  of  the  uvula  may  produce  sympathetic  vomiting, 
which  may  also  occur  in  certain  affections  of  the  brain.  In  ner- 
vous persons,  vomiting  frequently  follows  a  severe  moral  or  phy- 
sical shock  ;  various  acute  diseases,  and  particularly  the  eruptive 
fevers,  are  ushered  in  by  this  phenomenon.  From  the  frequency 
of  this  symptom,  and  from  the  numerous  affections  in  which  it 
occurs,  it  becomes  highly  important  for  the  physician  to  be  familiar 
with  all  the  circumstances  connected  with  it,  and  the  diseases  to 
which  it  belongs.  We  shall  again  refer  to  this  subject  in  the 
chapter  on  diagnosis. 

The  matters  rejected  by  vomiting,  vary  in  their  nature,  consis- 
tence, quantity,  color  and  odor. 


rumination. 


SYMPTOMS.  127 

These  may  consist  of  the  residue  of  digestion,  as  in  the  attack 
of  acute  diseases,  mucus,  green  or  yellow  bile,  various  medi- 
cinal, and,  in  cases  of  poisoning,  poisonous  substances,  &c.  They 
may  consist;  1,  of  liquid  or  coagulated  blood  in  haemorrhage  of 
the  stomach,  which  is  generally  symptomatic  ;  2,  of  a  brownish, 
black,  pultaceous  substance,  resembling  chocolate  or  coffee  grounds, 
in  cancer  of  this  organ ;  3,  of  pus  when  an  abscess  opens  into 
its  cavity ;  4,  of  fsecal  matters,  when,  from  any  cause,  occlusion  of 
the  intestines  has  taken  place.  We  saw  at  the  Hotel  Dieu  a  man, 
suffering  from  articular  rheumatism  following  dysentery,  reject,  by 
vomiting,  a  bloody  and  viscid  substance,  resembling  in  appearance 
the  sputa  in  pneumonia.  In  cholera,  the  matters  vomited  resemble 
rice  water  or  whey ;  in  one  case  they  exactly  resembled  milk,  both 
in  color  and  consistence.  Among  them  are  also  sometimes  found 
lumbrici,  hydatids  and  biliary  calculi ;  also  portions  of  cysts,  false 
membranes  or  tumors  which  -have  been  detached  from  the  inner 
surface  of  the  stomach,  or  some  other  part  of  the  digestive  canal. 

The  consistence  of  these  matters,  is  variable  ;  they  are  generally 
liquid,  sometimes  clear  and  watery,  at  others,  thick,  viscid  and 
resembling  paste.  They  are  sometimes  mixed  with  a  certain 
quantity  of  gas  or  solid  matters,  as  in  indigestion.  Their  quantity 
may  vary ;  this,  in  many  cases,  it  becomes  highly  important  accu- 
rately to  ascertain,  particularly  in  the  vomiting  of  pus  and  blood. 
Their  color  and  odor  generally  depend  upon  their  nature. 

Some  patients  while  making  the  most  violent  efforts  to  vomit, 
reject  nothing  but  gas,  which  is  generally  insipid  and  inodorous, 
and  produced  by  simple  exhalation.  This  is  observed  in  certain 
neuroses,  and  particularly  in  hysteria.  In  the  "single  case  of  dry 
cholera,  observed  by  Sydenham,  in  the  autumn  of  1669,  there  was 
evacuation  of  wind  from  above  and  below,  without  any  other 
excretion. 

5.  The  pain  of  which  the  epigastrium  is  the  seat,  varies  in  its 
character,  type,  intensity,  and  particularly  in  its  causes.     Ot  these, 
the  principal  are,  inflammation  of  the  stomach,  the  presence  of 
indigestible  or  poisonous  substances  in   this  viscus,  the  various 
organic  affections  peculiar  to  it,  rheumatism  of  the  muscles  of  this 
region,  the  constriction  of  a  portion  of  the  epiploon  in  an  opening  of 
the  linea  alba,  peritonitis,  any  affection  of  the  liver  or  pancreas,  an 
acute  or  chronic  affection  of  the  lungs  and  pericardium  accom- 
panied by  a  frequent  cough,  leucorrhoea,  habitual  pressure  on  the 
epigastrium  by  tight  corsets,    hysteria,  &c.     This  enumeration, 
though  incomplete,  is  sufficient  to  show  the  error  of  those  who 
refer  all  epigastric  pain  to  inflammation  of  the  stomach.     There 
are  few  grave  diseases  which  may  not  be  accompanied  by  epigas- 
tric pain. 

6.  Pain  in   the  stomach,  of   a  peculiar  character,    sometimes 
occurs,  to  which  the  term  cramp  in  the  stomach  has  been  applied  : 
it  is  compared  by  patients  to  the  pain  caused  by  cramp  in  the 
muscles  of  the   leg,  and  generally  produces  forced  flexion  of  the 
body  forward,  during  the  whole  time  of  its  duration. 


128  SYMPTOMS. 

7.  There  is  still  another  symptom  furnished  by  the  stomach,  and 
to  which  authors  have  not  referred.  This  consists  of  a  peculiar 
sound  caused  by  the  fluids  and  gases  contained  in  this  viscus,  and 
which  may  be  produced  by  a  slight  blow  upon  the  trunk,  or  rapid 
pressure  made  with  the  hand  over  the  epigastric  region,  and  several 
times  repeated.  This  phenomenon  occurs  mostly  in  diseases  ac- 
companied by  distension  of  the  parietes  of  the  stomach,  and  par- 
ticularly in.  cancer  of  the  pylorus.  It  is  sometimes  met  with  in 
healthy  mdi\  iduals. 

G.  The  symptoms  furnished  by  the  intestinal  canal  are  less 
numerous  and  more  difficult  to  distinguish.  Among  these  may  be 
mentioned  those  internal  movements,  sometimes  felt  in  diarrhoea, 
the  commotion  and  twisting  occasionally  experienced  by  patients  at 
the  commencement  of  dysentery,  those  various  movable  pains, 
of  a  dull,  rather  than  acute  character,  sometimes  followed  by  cold 
sweats  and  fainting,  and  which  have  been  termed  intestinal  colic 
or  simply  colic,  occurring  in  inflammation  of  different  portions  of 
the  intestinal  canal,  particularly  the  colon,  lastly,  those  partial  tu- 
mefactions of  the  abdomen,  produced  by  the  gaseous  distension  of 
some  part  of  the  intestinal  canal,  or  by  agglutination  of  the  intes- 
tines with  each  other,  &c.  These  symptoms  need  only  to  be 
enumerated.  There  are  some  others  which  should  be  mentioned 
more  in  detail;  as  borborygmi,  and  also  those  various  changes 
which  supervene  in  the  course  and  excretion  of  matters  and  in 
the  matters  themselves. 

1.  The  term  borborygmi*  is  applied  to  the  sound   produced  by 
displacement  of  the  gases  contained  within  the  abdomen.     These 
noises  accompany  intestinal  disorders  and  hypochondriasis ;  they 
are  not  unfrequently  observed  in  healthy  persons,    particularly 
females,  and,  as  has  been  before  remarked,   are  often  caused  by 
habitual  compression  of  the  abdomen. 

2.  There  is  another  intestinal  sound,  somewhat   analogous  to 
borborygmi,  but  differing  in  being  more  moist  and  generally  more 
circumscribed.     We  refer  to  the  gurgling  (gargouillement),  often 
heard  in  intestinal  hernia,  particularly  while  employing  taxis  in 
its  reduction ;  it  is  here  produced,  as  in  the  stomach,  and  cavities 
of  the  lungs,  by  the  concussion  of  liquid  or  gaseous  matters  con- 
tained in  a  cavity.     An  analogous  sound  occurs  in  schirrus  con- 
traction and  internal  strangulation  of  a  portion  of  the  intestines, 
which  aids  in  their  diagnosis.     But  it  is  chiefly  in  typhoid  fever 
that  gurgling,  which  is  confined  to  the  coecal  region,    and  ordi- 
narily accompanied  by  local  pain  on  pressure,  becomes  an  important 
sign.     Of  all  acute  affections,  typhoid  fever  is  the  only  one  in 
which  this  symptom  exists,  being  in  this  disease  almost  constant, 
although  varying  in  intensity  and  duration  ;  it  is  owing  to  a  pecu- 
liar  alteration  affecting  the  ilio-crecal  valve   and  the   extremity 
of  the  small  intestines   which  is  peculiar   to   this  disease.      In 

,  from  poQpoqvtw,  I  make  a  dull  noise. 


SYMPTOMS.  129 

obscure  cases  this  phenomenon  becomes  an  important  diagnostic 
sign. 

3.  The  course  of  alimentary  matters   through    the   intestinal 
canal,  may  be  retarded  or  accelerated,  as  we  shall  see  hereafter, 
in  referring  to  their  characters.     Under  certain  circumstances,  in 
consequence  of  grave  and  rare  lesions  of  the  intestines,  the  alimen- 
tary matters  may  arrive  at  the  termination  of  the  intestinal  tube, 
without  having  traversed  its  whole  extent.     In  the  examination  of 
the  body  of  an  aged  woman  who  died  at  Salpeteriere,  in  whom 
there  was  disease  of  the  gall-bladder,  a  large  communication  was 
discovered,  which  permitted  the  finger  to  pass  from  the  duodenum 
into  the  enlarged  gall-bladder,  and  from  the  latter  into  the  trans- 
verse colon ;  a  yellowish  mass  which  filled  these    three  organs 
clearly  indicated  the  course  of  the  alimentary  matters.     Perfora- 
tions between  contiguous  portions  of  the  intestine,  have  been  often 
observed,  producing  similar  results.     Patients,  in  these  cases,  are 
in  a  condition  analogous  to  that  produced  by  an  artificial  anus. 

4.  The  alvine  excretion  or  defecation  (alvina  excretio,  defcecatio) 
is  the  act  by  which  the  contents  of  the  rectum  are  expelled  from 
the  body.     This  may  be  more  or  less  frequent  than  in  the  natural 
state,  constituting,  in  one  case,   diarrhoea  (alvus  citd),  and  in  the 
other,  constipation  (aim  obstipatio,  alvus  compressa). 

These  two  symptoms  are  so  frequent,  that  there  are  few  serious 
diseases  in  which  one  or  the  other,  and  sometimes  both  succes- 
sively, may  not  exist.  Constipation  and  diarrhoea  sometimes  exist 
to  an  almost  incredible  degree ;  some  patients  have  been  known  to 
have  no  evacuation  for  several  months ;  in  others,  on  the  contrary, 
the  excretions  are  so  frequent  as  almost  to  allow  no  interval 
between  them.  We  recollect  a  patient  at  the  hospital  De  la  Charite, 
who  was  obliged  for  several  days  to  keep  a  vessel  constantly  be- 
neath him :  the  excretions  were  so  frequent  as  hardly  to  allow 
sufficient  time  for  the  vessel  to  be  emptied  of  its  contents. 

Constipation,  when  habitual,  and  existing  within  certain  limits, 
is  not  a  serious,  and  often  not  a  morbid  symptom.  There  are 
individuals  who  do  not  go  to  stool  oftener  than  once  in  eight,  ten, 
or  even  fifteen  days,  and  experience  no  inconvenience  whatever. 
It  is  otherwise,  if  constipation  supervene  accidentally  in  persons 
not  habitually  disposed  to  it,  particularly  if  accompanied  with 
other  derangements  of  health  ;  it  is  owing  in  such  cases,  either  to 
a  want  of  action  in  the  intestines  themselves,  or  to  some  obstacle 
to  the  course  of  the  faecal  matters.  In  the  most  aggravated  cases  of 
this  affection,  the  contents  of  the  distended  intestine,  which  cannot 
be  excreted,  are  rejected  by  the  mouth.  To  this  complex  phenome- 
non, marked  by  obstinate  constipation,  and  the  vomiting  of  the 
contents  of  the  stomach  and  intestines,  the  term  ileus  has  been 
applied.  This,  which  the  ancients  considered  a  disease,  is  in  fact 
but  a  symptom,  and  may  be  occasioned  by  all  the  causes  capable 
of  producing  occlusion  of  the  intestines,  as  external  and  internal 
strangulation,  invagination,  schirrus  contraction,  tumors  situated 
either  without  or  within  their  cavity,  a  foreign  body,  and  sometimes, 


130  SYMPTOMS. 

particularly  in  old  persons,  a  voluminous  mass  of  indurated  faeces. 
The  latter  cause  may  produce  a  kind  of  hectic  fever  called 
stercoral,  and  even  death.  It  is  important  that  the  physician  be 
familiar  with  all  the  causes  capable  of  producing  constipation,  and 
ileus,  which  is  sometimes  dependent  upon  it. 

Defecation  may  be  accompanied  with  pain  in  the  anus  or  in  the 
abdomen ;  these  pains  almost  always  occur  in  constipation  ;  they 
are  sometimes  absent  at  the  commencement  of  diarrhoea,  but 
often  supervene  when  this  affection  has  lasted  for  several  days  and 
the  evacuations  have  become  very  frequent.  In  certain  diseases 
of  the  rectum,  defecation  is  exceedingly  painful.  To  this  pain  is 
sometimes  added  a  constant  and  ineffectual  desire  to  go  to  stool 
together  with  a  burning  and  smarting  sensation  about  the  anus ; 
this  constitutes  tenesmus  or  epreintes  (desidendi  conatus),  a  symp- 
tom peculiar  to  dysentery.  Tenesmus  is  sometimes  followed  by 
no  excretion,  sometimes  a  small  quantity  of  bloody  mucus  is 
squeezed  out  with  violent  efforts.  Tenesmus  should  not  be  con- 
founded with  the  pain  excited  by  the  excretion  of  faecal  matters 
in  persons  affected  with  haemorrhoids,  fissures,  or  contraction  of 
the  anus ;  in  all  these  cases,  the  excreted  matters  are  of  a  healthy 
consistence  ;  they  act  mechanically  upon  the  parts,  which  they  irri- 
tate, but  the  desire  of  going  to  stool  is  only  felt  at  remote  intervals, 
and  the  pain  ceases  or  becomes  diminished  during  the  intervals. 
In  tenesmus,  on  the  contrary,  the  pain  and  desire  to  evacuate  are 
constant,  and  the  excreted  matters  are  either  remarkably  altered 
or  do  not  exist  at  all.  Tenesmus  does  not  necessarily  indicate  an 
affection  of  the  large  intestine.  It  sometimes  depends  upon  pres- 
sure exerted  upon  the  rectum,  by  a  tumor  in  the  pelvis,  or  in  the 
uterus  towards  the  close  of  gestation.  Tenesmus  in  the  male 
may  be  also  owing  to  the  presence  of  a  calculus,  of  greater  or  less 
size,  in  the  bladder. 

Defecation,  under  some  circumstances,  takes  place  independently 
of  the  will  of  the  patient.  This  symptom  presents  itself  under 
various  forms:  1,  in  some  cases  of  diarrhoea,  in  which  the  patient, 
thinking  to  expel  wind,  involuntarily  allows  the  escape  of  fluid 
matters ;  the  same  phenomenon  frequently  occurs  in  schirrus  of 
the  rectum ;  2,  at  other  times  he  experiences  a  pressing  desire  to 
evacuate,  and  the  excretion  takes  place  in  spite  of  all  his  efforts  to 
the  contrary ;  3,  in  other  cases,  it  occurs  without  producing  any 
sensation,  and  sometimes,  even  without  the  knowledge  of  the 
patient ;  this  happens  in  violent  acute  diseases,  and  towards  the 
close  of  chronic  affections.  This  incontinence  of  faecal  matters, 
has  been  also  observed  in  affections  of  the  spinal  marrow  :  invol- 
untary discharge  of  these  matters  or  of  flatus,  is  often  the  first 
index  of  these  diseases. 

There  are  some  cases  in  which  the  excretion  of  the  faeces  be- 
comes otherwise  deranged ;  the  faecal  matters  are  sometimes  ex- 
pelled from  the  body,  before  having  traversed  the  whole  length  of 
the  intestinal  canal.  Either  from  the  opening  of  an  abscess  into 
the  intestinal  cavity  or  a  wound  of  these  organs,  and  more  fre- 


SYMPTOMS.  131 

quently  from  tfre  occurrence  of  gangrene  in  strangulated  hernia, 
there  is  formed  in  the  place  of  the  wound  or  hernial  tumor,  either 
a  small  opening  called  a  stercoral  fistula,  through  which  a  part  of 
the  intestinal  contents  pass,  or  a  supplementary  or  artificial  anus, 
which  gives  issue  exclusively  and  uninterruptedly  to  the  faecal 
matters. 

In  some  cases,  in  which  the  intestine  opens  into  the  bladder, 
these  matters  are  expelled  mixed  with  the  urine,  but  being  here 
also  retained  by  a  sphincter,  the  patient  is  in  the  same  disgusting 
condition,  as  if  suffering  from  an  artificial  anus.  In  a  very  re- 
markable, and  perhaps  the  only,  case  on  record,  the  faecal  matters 
pursued  a  still  more  extraordinary  course.  An  old  woman  was 
admitted  to  the  Hotel  Dieu  (service  of  Dr.  Husson)  in  such  a  state 
of  debility,  as  to  be  unable  to  give  any  account  of  her  complaihts. 
All  that  was  noticed  was  that  the  bed  was  continually  soiled  by 
faecal  discharges.  Upon  examining  the  body  after  death,  the  large 
intestines  were  found  completely  filled  with  voluminous  faces,  of 
a  stony  hardness,  and  which  must  have  been  retained  for  several 
months ;  upon  further  examination,  it  was  ascertained  that  owing 
to  cancerous  ulceration,  a  communication  had  been  formed  between 
the  large  intestine  and  the  fundus  of  the  uterus,  and  that  all  the 
faecal  matters  passed  through  the  cavity  of  the  latter  organ  and 
vagina,  and  ran  out  at  the  vulva.  The  specimen  was  presented 
to  me  by  Dr.  Husson,  the  younger,  and  it  has  since  been  exhibited 
to  the  students,  in  the  amphitheatre  of  the  Hotel  Dieu. 

4.  The  excreted  matters  or  excrements  (faces)  present,  in  dis- 
ease, numerous  alterations,  according  to  their  nature,  consistence, 
quantity,  color,  odor,  form,  and  the  foreign  substances  occasionally 
found  with  them. 

These  matters  may  be  watery,  as  in  the  intestinal  flux  with 
which  Morgagni  was  attacked,  and  serous  diarrhoea ;  they  may 
partake  of  a  mucous  character,  resembling  the  white  of  an  egg  or 
the  spawn  of  frogs,  in  some  cases  of  chronic  colitis  ;  they  are  bilious 
in  many  diseases;  their  admixture  with  a  certain  quantity  of 
chyme,  constitutes  the  codiac  flux  ( fluxus  ccBliacus)  *  [chylous 
diarrhcea] ;  they  consist  of  half  digested  food  in  lientery  (lienterid)^ ; 
they  are  streaked  with  blood  in  some  cases  of  diarrhoea  in  which 
the  stools  are  very  frequent ;  blood  is  uniformly  mixed  with  the 
mucous  discharges  in  dysentery ;  it  flows  pure  and  liquid  from 
the  anus,  when  it  comes  from  the  rectum,  and  particularly  in  the 
haemorrhoidal  flux  ;  it  is  black  and  changed  when  from  the  stom- 
ach, as  is  often  observed  after  haematemesis,  in  persons  affected 
with  cancer  of  this  organ.  Liquid  blood  of  a  blackish  color  and 
very  fetid  odor,  when  discharged  from  the  anus  in  large  quantities, 
and  in  the  course  of  a  continued  fever,  indicates,  almost  with 
certainty,  the  existence  of  liberations  in  Peyer's  patches,  and 
becomes  in  some  obscure  cases  a  very  important  diagnostic  sign ; 

*  JToiJia,  belly. 

t  jJfievreQia,  from  Ztiog,  smooth,  and  erreoor,  intestine. 


132  SYMPTOMS. 

for  among  all  the  acute  affections  peculiar  to  our  climate,  typhoid 
fever  is  the  only  one  in  which  these  hemorrhages  occur.  Lastly, 
a  frequent  or  continual,  and  often  involuntary,  discharge  of  sanious 
and  stercoral  matters,  is  one  of  the  characteristic  signs  of  cancer 
of  the  rectum,  and  sometimes  of  fistula  in  ano.  Finally,  this 
excretion  may  be  mixed  with  pus  in  chronic  inflammation  and 
ulceration  of  the  intestines ;  it  is  entirely  purulent  when  an  abscess, 
contiguous  to  the  intestinal  canal,  opens  and  discharges  itself 
into  it. 

The  matters  excreted  from  the  anus  may  be  in  a  gaseous, 
liquid,  or  solid  form.  The  faetidity  of  the  gases  becomes  increased 
in  intestinal  disorder  and  putrid  fevers ;  their  quantity  becomes 
greater  in  hypochondriacs,  who  are  relieved  by  its  emission :  this 
excretion  is  sometimes  suspended  in  obstinate  constipation ;  it  is 
painful  in  inflammation  of  haemorrhoidal  tumors,  dysentery,  &c. 
Excreted  matters  are,  in  some  diseases,  harder  than  in  health,  as 
in  cancer  of  the  stomach,  and  particularly  lead  colic :  in  the  latter 
disease  they  form  small  black  hard  balls,  resembling  the  excre- 
ment of  sheep,  and  are  hence  called  ovilles.*  When  liquid,  they 
vary  in  consistence  from  that  of  water  to  that  of  pulp :  in  the 
latter  case  they  are  termed  pultaceous.\ 

The  quantity  of  excreted  matters  varies,  both  in  each  particular 
excretion,  and  relatively  to  the  number  of  excretions  in  a  given 
time.  At  the  commencement  of  dysentery,  the  quantity  of  rnucus 
expelled  is  so  small  as  to  resemble  the  sputa,  and  hardly  to  stain 
the  linen  with  which  it  comes  in  contact.  In  certain  cases  of 
diarrhoea  following  obstinate  constipation,  and  in  cancerous  con- 
traction of  the  intestines,  a  single  excretion  sometimes  furnishes 
several  pounds  of  faecal  matter.  When  the  discharges  are  very 
frequent,  as  in  the  dysentery  observed  by  Zimmerman,  in  which 
some  patients  went  to  stool  two  hundred  times  in  twelve  hours, 
the  quantity  of  matter  excreted  was  very  considerable. 

The  form  of  the  faecal  matters,  it  is  sometimes  highly  important 
to  ascertain ;  as  in  cases  of  cancer  of  the  rectum  previous  to  ul- 
ceration, in  which  they  are  elongated,  and  often  flattened  into  the 
form  of  a  ribbon,  and  preserving  to  a  certain  extent  the  size  and 
form  of  the  intestinal  contraction. 

The  excretions  are  sometimes  transparent  and  colorless,  common- 
ly opaque,  and  of  a  yellow,  brownish  or  greenish,  and  sometimes 
white,  black  or  red  color.  The  yellow  color  depends  upon  the 
quantity  of  bile  they  contain.  The  peculiar  color  of  yellow  ochre, 
which,  they  sometimes  present  in  typhoid  fever,  is  thought  by  Dr. 
Bright  to  indicate  the  period  when  ulceration  of  the  intestines 
takes  place.  This  opinion  of  the  English  pathologist  has  not  as 
yet  been  verified.  Fluid  alvine  discharges,  in  which  occur  a  greater 
or  less  quantity  of  thick  and  whitish  clots,  resembling  a  decoction 
of  rice  or  whey,  were  characteristic  of  the  Asiatic  cholera  ;  it  was 

*  Ovis,  sheep, 
f  Puts,  pulp. 


SYMPTOMS.  133 

shown  by  chemical  analyses  made  at  Moscow,  Warsaw,  Berlin, 
London,  and  Paris,  that  a  portion  of  the  elements  of  the  blood, 
the  serum  and  the  salts,  were  then  evacuated  by  the  intestine, 
and  that  the  white  flocculi  were  formed  by  albumen  in  the  con- 
crete form,  which  seemed  to  be  in  excess  in  patients  affected  with 
his  disease. 

If  the  stools  be  of  a  deep  black  color,  the  presence  of  blood  is 
indicated ;  a  dark  green  color  depends  upon  the  presence  of  bile. 
The  excreted  matters  sometimes  resemble  chocolate  or  coffee 
grounds,  which  indicates  that  sanguineous  exhalation  has  taken 
place  in  the  upper  portion  of  the  digestive  tube,  particularly 
the  stomach ;  it  is  owing  to  blood  which  has  undergone  partial 
digestion. 

The  peculiar  fetidness  of  the  excrements  often  becomes  increased 
in  disease ;  a  cadaverous  odor  is  noticed  in  adynamic  fevers  and 
chronic  ulceration  of  the  intestines.  They  exhale  the  odor  of 
anatomical  maceration  in  certain  cases  of  malignant  dysentery. 

The  faecal  matters  may  contain  foreign  bodies,  formed  within 
the  body,  or  introduced  from  without.  They  often  present  mucous 
pellicles  or  shreds,  which  appear  to  be  the  result  of  phlogosis  of 
the  mucous  coat,  or  of  gangrene  or  ulceration  of  this  membrane; 
portions  of  intestine  which  have  become  separated  by  gangrene 
after  intestinal  invagination,  have  been  found  in  them ;  also  tu- 
mors, biliary  or  intestinal  calculi,  different  species  of  worms,  &c. 

Foreign  bodies  from  without  present  the  greatest  variety  :  they 
are  sometimes  substances  incapable  of  affording  nourishment ;  and 
sometimes,  partially  digested  alimentary  matters.  Kernels  envel- 
oped in  their  epidermis,*  as  dry  peas,  for  example,  which  have 
been  retained  for  several  months,  have  been  expelled  unchanged. 

The  changes  which  take  place  in  the  nature,  consistence,  quan- 
tity, and  color  of  the  excreted  matters,  do  not  depend  solely  upon 
disease,  being  also  the  effect  of  remedies.  The  influence  of  pur- 
gatives upon  the  frequency  of  the  alvine  excretions  and  consist- 
ence of  the  excreted  matters,  is  familiar  to  every  one.  Rhubarb 
imparts  to  them  a  yellow  and  sometimes  a  reddish  color,  resem- 
bling water,  to  which  a  few  drops  of  blood  have  been  added. 
The  preparations  of  iron  give  them  a  black  color,  probably  from 
the  formation  of  a  sulphuret  of  iron ;  calomel  imparts  to  them  a 
dark  green  color.  Under  these  circumstances  it  is  important  not 
to  confound  the  phenomena  of  the  disease  with  those  produced  by 
remedies. 

*  De  Sedib.  et  Caus.  morb.  epist.  xxxi.  art.  27. 


12 


134  SYMPTOMS. 


SECTION    SECOND. 

Symptoms  furnished  ly  Respiration. 

In  the  healthy  condition,  the  respiration  is  easy,  regular,  and 
without  noise ;  its*  frequency,  that  is,  the  number  of  inspirations 
and  expirations  in  a  given  time,  is  relative  to  the  age  and  condi- 
tion of  each  individual.  The  number  of  respirations  is  generally 
about  thirty-five  per  minute  in  the  first  year  of  life,  twenty-five  in 
the  second,  twenty,  at  puberty,  and  eighteen  in  the  adult  age. 
It  is  a  little  more  in  females,  lively  persons  and  those  of  small 
stature,  than  in  those  in  opposite  conditions  ;  this  number  becomes 
increased  in  all  persons  after  physical  exercise,  declamatory  efforts, 
profound  emotions,  &c.  The  dilatation  of  the  chest  in  infancy 
takes  place  principally  by  the  motion  of  the  ribs ;  in  old  age,  by 
that  of  the  diaphragm,  and,  in  the  adult,  by  the  movements  of 
both  combined. 

In  disease,  respiration  furnishes  numerous  symptoms.  Having 
first  studied  those  which  belong  to  the  alternate  movements  of 
inspiration  and  expiration,  we  shall  proceed  to  consider  those 
which  are  accidental,  as  coughing,  sneezing,  &c. 

$  I.  Respiration,  considered  in  the  alternate  movements  of 
inspiration  and  expiration,  presents  numerous  changes  in  respect, 
1,  to  the  frequency  of  these  movements;  2,  their  quickness;  3,  the 
quantity  of  air  inspired  and  expired ;  4,  the  difficulty  of  respira- 
tion ;  5,  its  irregularities ;  6,  the  sound  accompanying  it ;  7,  the 
qualities  of  the  air  expired ;  8,  and  finally,  to  these  phenomena 
should  be  added  those  furnished  by  auscultation,  succussion,  per- 
cussion, inspection,  and  mensuration  of  the»  chest. 

In  order  for  the  physician  to  appreciate v  these  various  changes, 
the  patient  should  either  be  seated  or  upon  the  back ;  he  should 
wait  till  the  emotion  occasioned  by  his  presence  shall  have  passed 
away,  and  even  then  avoid  the  appearance  of  examining  this 
function,  since  such  is  the  influence  of  the  will,  that  it  ceases  to 
act  according  to  its  ordinary  rhythm  the  moment  it  attracts  the 
attention  of  the  patient.  The  most  simple  mode  of  accomplishing 
this,  is  to  place  the  finger  upon  the  pulse  of  the  patient,  while 
counting  with  the  watch  the  number  of  respirations  in  the 
minute. 

1.  Respiration  is  frequent,  when  the  number  of  inspirations  and 
expirations  is  greater,  in  a  given  time,  a  minute  for  example,  than 
in  the  ordinary  condition ;  it  is  rare,  when  the  number  is  less.  It 
is  only  in  cerebral  affections  that  rareness  of  the  respiration  is 
observed.*  Its  frequency,  on  the  contrary,  is  increased  in  a  great 
number  of  diseases,  and  especially  those  of  the  heart  and  lungs. 

*  Floyer  counted  as  few  as  seven  respirations  in  the  minute,  in  more  than  one 
case  of  asthma  ;  and  Graves  has  recorded  as  few  as  twelve  in  some  cases  of 
fever.  —  TRANS. 


SYMPTOMS.  135 

2.  Respiration  is  quick  when  the  movements  of  inspiration  and 
expiration  are  performed  with  rapidity  ;  slow,  in  opposite  condi- 
tions.     Quickness  and  frequency,   slowness  and   rareness,  exist 
simultaneously  in  most  thoracic  diseases.     In  some  cases,  how- 
ever, as  in  pleurisy,  respiration  is  quick  without  frequency,  or  at 
least  its  quickness  far  surpasses  its  frequency  ;  at  other  times,  it  is 
quick  and  rare,  as  in  the  agony,  in  which  the  patient  at  long  inter- 
vals makes  a  rapid  but  ineffectual  effort  at  inspiration,  which  is 
succeeded  by  an  interval  of  repose. 

3.  Respiration   is  full  when  the   quantity  of  air  inspired  is 
greater  than  usual  ;  small  when  less,  as  in  pleurisy  and  peripneu- 
monia. 

The  dilatation  of  the  chest,  and  consequently  the  quantity  of 
air  which  penetrates  the  lungs,  is  not  always  equal  in  the  two 
sides.  Pleuritic  effusion,  or  the  hepatization  of  a  lung,  is  a  more  or 
less  complete  obstacle  to  the  entrance  of  the  air  into  the  corres- 
ponding side.  If  the  patient's  chest  be  uncovered,  it  will  be  seen 
that,  while  the  movements  of  one  side  are  in  the  normal  propor- 
tion, the  other,  which  is  the  diseased  side,  remains  immovable, 
or  nearly  so.  If,  instead  of  examining  these  phenomena  by  the 
eye  only,  one  of  the  hands  be  placed  on  each  side  of  the  chest  a 
little  below  and  outside  the  nipples,  these  differences  become 
doubly  evident,  being  marked  in  proportion  to  the  quantity  of  air 
which  the  patient  is  compelled  to  inspire  into  one  lung,  in  order 
to  the  performance  of  the  functions  of  both. 

4.  Dyspnoea*  or  difficulty  of  respiration,  presents  itself  under 
various  forms.     Respiration  is  simply  laborious,  when  the  respi- 
ratory efforts  of  the  patient  do  not  oblige  him  to  remain  seated. 
In  many  cases,  it  is  not  experienced  by  the  patient,  except  after  a 
hurried  walk,  or  ascending  a  flight  of  stairs.     If  the  dyspnoea 
compel  him  to  retain  the  sitting  posture,  it  is  called  orthopncea^ 
which  is  particularly  observed  in  the  advanced  stages  of  organic 
affections  of  the  heart,  in  the  paroxysm  of  suffocation  in  pulmo- 
nary emphysema  and  nervous  asthma,  and  in  double  hydrothorax 
and  simultaneous  inflammation  of  the  two  lungs.     When  there 
is  at  the  same  time  danger  of  suffocation,  it  is  termed  suffocating, 
panting  dyspnoea  ;  lastly,  there  is  painful  dyspnoea,  in  which  the 
thoracic  movements  are  as  it  were  arrested  by  the  pain  experienced 
in  executing  them,  as  in  pleurisy.     High  respiration  is  that  in 
which  the  patient  is  obliged  to  remain  sitting,  as  in  orthopnaea, 
and  to  dilate  the  thorax,  by  elevating  its  sides,  as  in  full  respira- 
tion.    Difficulty  of  respiration  is*sometimes  so  great,  that  the  con- 
tractions of  the    inspiratory  muscles,    and  particularly  those  of 
the  diaphragm,  are  as  it  were  convulsive  :  the  chest  and  abdomen 
are  alternately  raised,  the  neck  is  bent  backward,  the  point  of  the 
sternum,  at  each  inspiration,  is  drawn  towards  the  spine,  partic- 
ularly in  children,  and  in  some  cases  all  the  muscles  in  the  body 


*  Jvartvota,  from  Svg,  with  difficulty,  and  nvtw,  I  breathe. 
t  OgQoTivoia,  from  OQ&O?,  right,  and  7rveu>,  1  breathe. 


136  SYMPTOMS. 

are  in  a  state  of  spasm,  indicative  of  the  anxiety  of  the  patient 
and  of  his  inability  to  produce  sufficient  dilatation  of  the  chest. 
Finally,  respiration  may  be  completely  suspended,  constituting 
apncea*  Difficulty  of  respiration  presents  also  this  remarkable 
peculiarity,  that  in  some  cases,  both  the  inspiration  and  expira- 
tion are  equally  difficult,  and  in  others,  one  of  these  movements, 
which  is  always  expiration,  is  performed  with  a  degree  of  free- 
dom, while  the  other  is  very  laborious,  as  is  observed  in  oedema  of 
the  glottis. 

In  some  cases  of  habitual  dyspnoea,  it  is  important  accurately  to 
ascertain  the  period  at  which  this  phenomenon  first  made  its 
appearance,  as  this  knowledge  may  enable  us  to  determine  the  na- 
ture of  the  organic  lesion  which  produces  this  derangement;  it 
appears  from  the  researches  of  M.  M.  Louis  and  Jackson,  that  dys- 
pnoea which  has  lasted  from  infancy,  particularly  when  occurring 
in  paroxysms,  is  an  almost  pathognomonic  sign  of  pulmonary  em- 
physema, f 

5.  Respiration  is  unequal  when  the  quantity  of  air  inspired 
varies  in  a  certain  number  of  successive  inspirations ;  it  is  irregu- 
lar when  the  intervals  between  the  alternate  movements  of  respi- 
ration are  unequal,  or  do  not  occur  in  the  usual  order;    as  in 
intermittent  respiration,  in   which  the   interval   between  certain 
expirations  and  the  following  inspiration,  is  sufficiently  long  for 
the  performance  of  an  entire  respiration ;  also  in  interrupted  res- 
piration (interrupta\  in  which  inspiration  and    expiration,  but 
half  performed,  succeed  each  other  with  rapidity,  without  being 
separated  by  an  interval  of  repose ;  also  in  broken  respiration,  in 
which  the  dilatation  of  the  chest  takes  place  by  several  inspiratory 
efforts,  and  its  contraction  by  as  many  successive  expiratory  move- 
ments.    This  respiration  resembles  that  of  persons  weeping;  it 
has  been  also  observed  in  hysteria,  and  often  in  the  rigor  which 
forms  the  first  stages  of  intermittent  fevers. 

6.  In  health,  a  slight,  and  almost  imperceptible  murmur  accom- 
panies respiration;    during  sleep,    there   may  be   more  or    less 
snoring.     In  disease,  the  respiration  may  become  sibilant,  sighing, 
plaintive,  stertorous,  or  rattling.     Sibilant  respiration  is  charac- 
terized by  a  peculiar  whistling  sound,  and  is  sometimes  heard  both 
in  inspiration  and  expiration,  as  in  the  most  severe  forms  of  pul- 
monary emphysema,  and  particularly  in  compression  of  the  trachea 
by  a  tumor ;  in  other  cases,  as  in  some  anginose  affections,  it  only 
accompanies  inspiration.     Sighing  respiration  (suspiriosa)  is  that 
in  which,  at  intervals,  after  a  full  inspiration,  prompt  expiration 
takes  place,    accompanied  by  a  peculiar   sound,   called  a  sigh. 
Plaintive  respiration  (luctuosa)  is  characterized  by  groaning  which 
accompanies  each  expiration  ;  this  has  been  particularly  observed 
in  phlegmasiae  of  the  chest,  and  in  some  grave  fevers.     A  sound  like 
that  of  Si  flute,  or  that  produced  by  a  brazen  tube,  sometimes  ac- 
companies inspiration.    This  symptom  is  not  unfrequently  noticed 

*  A  privitive,  TTSVO,  I  breathe 

t  Mem.  de  la  Soc.  Med.  d'Observation,  p.  186. 


SYMPTOMS.  137 

in  croup ;  in  some  cases,  but  more  rarely,  expiration  is  alone  sono- 
rous, the  sound  in  the  inspiration  being  obscure.  Stertorous 
respiration,  is  that  accompanied  by  a  loud  and  vibrating  sound ;  it 
is  observed  in  severe  cases  of  apoplexy,  and  in  the  second  stage  of 
the  epileptic  paroxysm ;  in  rattling  respiration,  this  sound  is  more 
feeble.  Stertor  differs  from  snoring  in  the  difficulty  of  the  thoracic 
movements  attending  the  former,  and  in  the  place  where  it  is  pro- 
duced ;  stertor  appears  to  proceed  from  the  trachea  and  larynx ; 
snoring  from  the  nasal  fossse  or  posterior  part  of  the  mouth. 

7.  The  changes  produced  by  disease  in  the  expired  air,  relate  to 
its  temperature,  odor  and  chemical  composition.     The  breath  is 
burning  in  inflammatory  fever,  cold  in  adynamic  affections  and 
cholera.     Its  odor  is  sweetish  in  certain  febrile  diseases,  acid  in 
some  affections  of  the  stomach.     In  some  cases,  this  acidity  is  so 
marked  as  to  impregnate  the  air  of  the  apartment ;  this  symptom 
always  indicates  a  grave  and  generally  fatal  lesion  of  the  stomach. 
The  breath  is  fetid  and  nauseous  in  bilious  fevers  and  gastric 
irritation :  it  is  sometimes  alliaceous,  or  resembles  the  odor  of  a 
dead  body  after  maceration,  in  gangrene  of  the  lungs  and  certain 
cases  of  chronic  pleurisy  with  perforation,  sometimes  even  before 
the  sputa  present  this  character.     It  is  hardly  necessary  to  remark 
that  the  odor  of  expired  air  does  not  depend  solely  upon  diseases 
of  the  respiratory  organs;  those  of  the  teeth,  mouth,  nasal  fossae, 
and  pharynx  equally  affect  it,  as  in  mercurial  salivation,  scorbutic 
swelling  of  the  gums,  membranous  pharyngitis  and  sylphilitic  ul- 
ceration   of  the  throat,    affections   in  which  the  breath  becomes 
intolerably  fetid. 

Chemistry  has  furnished  physiology  with  valuable  results  in 
respect  to  the  changes  which  the  air  undergoes  in  the  healthy  lungs. 
It  is  to  be  regretted  that  it  has  not  yet  afforded  an  explanation  of  the 
modifications  which  are  incontestably  produced  in  the  various  affec- 
tions of  the  air  passages.  Inflammatory  induration  of  the  lungs, 
the  presence  of  tubercles  in  this  organ,  its  compression  by  pleuritic 
effusion,  inflammation  of  its  mucous  membrane,  together  with  the 
membranous  concretions  which  form  upon  it  in  some  cases,  are 
all  affections  in  which  the  air  that  penetrates  the  lungs,  undergoes 
modifications,  which  it  would  be  interesting  fully  to  appreciate, 
and  which  certainly  differ  from  those  that  take  place  in  health; 
unhappily,  the  researches  undertaken  by  Nysten  and  some  others, 
have  as  yet  thrown  little  light  upon  this  point  in  pathology.  It 
was  remarked  by  John  Davy  and  afterwards  by  M.  Rayer,  that,  in 
the  cold  stage  of  Asiatic  cholera,  no  change,  or  almost  none,  was 
effected  in  the  air,  by  respiration.  * 

8.  To  these  phenomena,  which  have  for  a  long  time  attracted 
the  attention  of  physicians,  may  be  added  those  discovered  by 
Laennec,  and  which  are  only  perceptible  by  means  of  an  acoustic 
cylinder,  called  a  stethoscope,!  or  by  the  immediate  application  of 

*  Gaz.  Medical,  1832. 

t  From  ortjQog,  chest,  and  OXOTCSW,  I  examine. 
12* 


138  SYMPTOMS. 

the  ear  to  the  chest.  This  method  of  exploration  constitutes  in  the 
first  case  mediate,  and  in  the  second,  immediate,  auscultation,  of 
which  Laennec  may  be  said  to  be  the  inventor  ;  for  if  it  be  true  that 
the  application  of  the  ear  to  the  parietes  of  the  chest,  and  the  ap- 
preciation of  the  sounds  there  produced,  be  twice  mentioned  in  the 
works  of  Hippocrates,  it  is  no  less  certain  that  these  two  passages, 
justly  forgotten  from  their  insignificance  and  obscurity,  did  not 
lead  to  the  discovery  of  a  method  of  exploration,  which,  in  a  few 
years,  Laennec  so  far  perfected,  that  time  has  neither  added  to, 
nor  detracted  from,  the  results  of  his  observation.* 

If  the  ear  be  applied  directly,  or  armed  with  the  stethoscope,  to 
the  chest  of  a  healthy  person,  during  inspiration,  a  very  soft  sound, 
or  murmur,  is  heard,  produced  by  the  entrance  of  air  into  the  cells 
of  the  lungs.  This  sound  is  not  equally  distinct  in  all  parts  of  the 
chest,  being  most  apparent  where  the  walls  of  the  chest  are  thinnest, 
as  in  the  hollow  of  the  armpits,  below  the  clavicles,  and  below 
and  within  the  scapulae.  It  is  much  louder  in  children  than  in 
adults.  In  the  latter,  it  varies  in  intensity,  independently  of  any 
lesion  of  the  lungs ;  in  some  persons  it  is  only  perceptible  during 
rapid  inspiration;  in  others  it  preserves  the  characteristics  of 
puerile  respiration  through  life.  If  auscultation  be  practised  dur- 
ing expiration,  no  sound,  in  some  cases,  can  be  distinguished  ;  in 
others,  a  slight  murmur  is  perceptible,  but  less  distinct  and  of 
shorter  continuance  than  that  heard  in  inspiration. 

In  disease,  the  natural  murmur  heard  during  inspiration,  may 
be  diminished,  cease,  be  increased  or  replaced  by  other  and  very 
different  sounds,  in  a  greater  or  less  portion  of  the  chest. 

The  respiratory  murmur  becomes  less  distinct,  at  the  com- 
mencement of  those  diseases  of  the  chest,  which  at  a  later  period 
cause  complete  suspension  of  the  respiratory  sound  in  the  portion 
of  lung  affected.  This  suspension  occurs  in  the  second  and  third 
stage  of  pneumonia,  in  emphysema,  cancerous  and  tubercular 
degeneration,  cysts  and  other  accidental  productions  developed  in 
the  pulmonary  tissue,  effusions  of  serum,  pus,  blood  or  air  into  the 
cavities.  The  vesicular  murmur  may  become  less  distinct,  or  en- 
tirely suspended,  throughout  a  greater  or  less  portion  of  the  lungs, 
when  there  is  compression  of  the  principal  bronchus,  by  a  tumor 
in  the  thorax.  This  is  sometimes  observed  in  cases  of  aneurism 
of  the  aorta,  and  this  symptom  may  indicate  the  direction  in  which 
the  tumor  is  developed.  In  some  of  these  diseases,  the  ear  can 
distinguish  no  natural  respiratory  murmur  or  sound  whatever ; 
this  is  the  case  in  great  pleuritic  effusion ;  in  most  other  diseases, 
the  respiratory  murmur  is  replaced  by  morbid  sounds,  to  which 
we  shall  allude  hereafter. 

The  absence  of  the  respiratory  sound  in  a  portion  of  the  chest, 
may  be  fixed  and  permanent  in  the  hepatization  of  pneumonia ; 

*  De  r Auscultation  Mediate,  ou  Traite  du  diagnostic  des  Maladies  des  poumons 
et  du  Caeur,  fondd  principalement  sur  ce  nouveau  moyen  d '  exploration,  par 
R.  T.  H.  LAENNEC. 


SYMPTOMS.  139 

Laennec  observed  in  some  cases  of  pulmonary  catarrh,  a  transient 
suspension  of  this  murmur  in  a  limited  portion  of  the  lungs,  a  phe- 
nomenon which  he  attributed  to  the  momentary  occlusion  of  some  of 
the  bronchial  tubes  by  the  mucus  secreted  by  the  parts ;  according 
to  him,  this  absence  of  the  respiratory  sound  may  cease  and  reap- 
pear alternately,  either  in  the  same  part  or  in  any  other.  We 
have  never  verified  this  phenomenon,  and  as  the  disease  alluded 
to  by  Laennec  is  a  very  frequent  one,  we  cannot  divest  ourselves 
of  some  doubts  as  to  its  production. 

The  respiratory  murmur  sometimes  becomes  more  intense  ;  thus 
it  may  acquire,  in  the  adult,  the  force  and  tone  which  it  presents 
in  children  after  forced  exercise,  in  certain  neuroses,  and  particu- 
larly when  the  other  lung  hasr  become  wholly  or  partially  unfit 
for  respiration.  In  the  latter  case,  the  respiratory  murmur  may 
be  increased,  not  only  in  the  healthy  lung,  but  also  in  the  healthy 
parts  of  the  diseased  lung. 

In  some  cases,  the  vesicular  sound  does  not  present  its  natural 
softness  and  smoothness,  but  becomes  rude  to  the  ear.  Rudeness 
of  the  respiratory  murmur,  as  it  occurs  in  inspiration  and  expira- 
tion, is  but  the  first  degree  of  bronchial  inspiration,  and  is  observed 
in  those  affections  in  which  the  latter  phenomenon  becomes  after- 
ward apparent. 

This  roughness  of  the  respiratory  sound  is,  in  some  cases,  per- 
ceptible in  the  expiration  before  becoming  so  in  inspiration ;  the 
expiration  is  often  at  the  same  time  prolonged.  Dr.  Jackson,  of 
Boston,  was  the  first  to  call  the  attention  of  physicians  to  this 
subject,  and  pointed  out  this  phenomenon,  when  existing  at  the 
summit  of  the  lungs,  as  indicative  of  incipient  tubercles.  M. 
Andral,  in  his  notes  to  Laennec' s  book,  and,  more  recently,  M. 
Fournet,  have  more  thoroughly  investigated  those  diseases  of  the 
lungs,  in  which  the  expiration  becomes  modified  either  in  force  or 
duration.  These  phenomena  are  important  in  the  diagnosis  of 
certain  thoracic  diseases,  at  that  period  of  their  development  when 
the  characteristic  signs  are  absent.  ^ 

In  certain  conditions,  the  soft  murmur  of  respiration  is  replaced 
by  a  louder  and  rougher  sound,  called  bronchial  or  tracheal  respi- 
ration. This  is  supposed  to  be  produced  in  the  principal  bronchial 
divisions,  by  resonance  of  the  air,  which  penetrates  but  partially  or 
not  at  all,  into  the  ultimate  ramifications  or  their  terminating  vesicles. 

This  sound  or  souffle  is  particularly  audible,  if  the  ear  be  applied 
over  an  indurated  portion  of  the  lungs  or  a  moderate  pleuritic 
effusion.  It  often  proceeds  from  a  dilated  bronchus,  or  from  exca- 
vations produced  by  ulceration  of  the  pulmonary  tissue ;  in  the 
latter  case  it  is  called  cavernous  respiration. 

This  last  variety  of  sound  is  generally  more  superficial  and 
circumscribed  than  ordinary  bronchial  respiration.  It  is  particu- 
larly observed  beneath  the  clavicles,  in  the  supra  and  infra  spinous 
fossae  and  in  the  axillae.  It  is  sometimes  intermittent,  the  cavity 
being  occasionally  filled  with  liquid,  or  the  bronchial  tube,  com- 
municating with  it,  being  obstructed  by  mucus. 


140  SYMPTOMS. 

Under  the  name  veiled  souffle  [souffle  voile],  Laennec  has  de- 
scribed a  variety  of  blowing  respiration,  which  is  heard  in  a  pul- 
monary cavity,  in  which  it  seems  as  if  each  vibration  of  the 
voice,  cough  or  respiration,  agitates  a  sort  of  movable  veil 
interposed  between  the  cavity  and  the  ear  of  the  observer.  Laennec 
pointed  out  this  phenomenon  as  occurring  in  those  tubercular 
cavities,  whose  walls  are  thin  and  not  adherent  to  the  chest, 
abscesses  of  the  lungs  while  surrounded  with  an  inflammatory 
induration,  and  some  cases  of  dilated  bronchi ;  this  phenomenon, 
according  to  him,  is  very  common  in  pneumonia,  when  the  tissue 
surrounding  the  bronchus  from  which  the  sound  proceeds,  remains 
healthy  or  has  suffered  but  slight  engorgement.  But  the  veiled 
souffle  of  Laennec  is  not  so  frequenf  as  has  been  supposed,  nor  has 
it  the  semeiological  value  which  has  been  attached  to  it.  It  may 
easily  be  confounded  with  the  other  degrees  of  bronchial  sound. 

The  last  variety  of  souffle  is  that  called  by  Laennec  the  amphoric 
sound,  from  its  resemblance  to  that  produced  by  blowing  into  an 
empty  vessel  with  a  narrow  neck,  as  a  decanter  or  bottle.  This 
phenomenon  is  produced  when  the  inspired  air  penetrates  into  a 
vast  hollow  cavity  in  the  parenchyma  of  the  lungs,  and  particu- 
larly when  it  passes  into  the  cavity  of  the  pleura,  through  an 
ulcerated  lung. 

The  different  modifications  of  the  respiratory  murmur,  just  in- 
dicated, become  increased  and  diminished  with  the  material  lesion 
on  which  they  depend,  furnishing  the  physician  with  valuable 
signs,  by  which  he  is  enabled  to  distinguish  a  diminution  or  in- 
crease in  the  local  disorder,  when  all  the  other  signs,  not  excepting 
those  afforded  by  percussion,  might  be  insufficient ;  the  return  of 
the  respiratory  murmur,  in  pneumonia  and  pleurisy,  for  example, 
sometimes  indicates  the  approaching  recovery  of  the  patient, 
several  days  before  the  disappearance  of  the  flat  sound  given  by 
percussion. 

Auscultation  of  the  chest,  besides  furnishing  the  physician  with 
the  means  o|pippreciating  the  changes  in  the  intensity  of  the  re- 
spiratory murmur,  also  enables  him  to  distinguish  the  different 
sounds  ordinarily  produced  by  the  passage  of  air  through  the 
various  liquids  which  may  be  contained  in  the  bronchi.  These 
various  sounds  have  by  Laennec  been  designated  by  the  term  rale 
or  rhonchus,  which  he  distinguished  into  the  crepitant,  subcrcpitant, 
mucous,  dry,  sonorous  and  sibilant. 

The  crepitant  rhonchus  or  crepitation,  is  a  slight  sound  heard 
on  auscultation,  and  which  has  been  compared  to  the  crepitation 
of  salt  when  thrown  upon  hot  iron.  It  is  almost  exclusively  heard 
in  inspiration,  and  does  not  always  entirely  mask  the  respiratory 
murmur,  which  becomes  less  distinct  at  this  point.  The  rhonchus 
which  presents  the  above  characteristics  only  occurs  in  the  first 
stage  of  pneumonia,  and  is  consequently  one  of  the  most  important 
signs  of  this  disease.*  It  is  of  equal  value,  when,  instead  of 

*  This  rhonchus  is  also  heard  in  certain  forms  of  pulmonary  congestion,  in 
eedema,  apoplexy  of  the  lungs,  and,  according  to  Stokes,  in  incipient  phthisis.  It 


SYMPTOMS.  141 

being  formed  by  numerous  and  distinct  bubbles,  it  conveys  to  the 
ear  a  dry,  continuous  sound,  resembling  that  produced  by  rubbing 
silk,  or  tearing  a  piece  of  taffeta.  The  latter  is  the  most  accurate 
comparison,  and  the  sound  is  often  designated  by  the  term,  bruit 
de  taffetas. 

There  is  another  crepitant  rhonchus  heard  in  the  commencing 
resolution  of  pneumonia,  when  the  lungs  are  passing  from  the  state 
of  red  hepatization  (second  degree)  to  simple  engorgement  (first 
degree).  This  has  been  called  byLaennec  the  crepitant  rhonchus 
of  return  or  subcrepitant,  being  a  variety  of  the  dry  crepitant, 
rhonchus.  It  is  formed  by  Bubbles,  which  are  numerous,  less 
regular,  larger  and  more  moist,  being  more  distinct  during  inspira- 
tion than  expiration.  It  belongs' also  to  capillary  bronchitis,  being 
particularly  evident  at  the  base  of  the  lungs.  Some  authors  have 
regarded  this  rhonchus  as  belonging  also  to  pulmonary  emphysema ; 
but  according  to  M.  Louis,  it  only  exists  in  this  disease  when  com- 
plicated with  pulmonary  catarrh,  and  in  this  case,  results  from  the 
bronchitis,  and  not  from  the  dilatation  of  the  vesicles.  When  this 
rhonchus  is  continuous,  confined  to  one  of  the  scapulae  fossae 
or  to  some  point  just  beneath  the  clavicles,  and  does  not  succeed 
pneumonia,  it  indicates  the  presence  of  tubercles  in  their  softening 
stage.  The  subcrepitant  rhonchus  which  depends  upon  this  grave 
lesion,  ordinarily  consists  of  bubbles  which  are  larger  and  fewer 
than  in  the  subcrepitant  rhonchus  of  simple  catarrh  ;  they  are  also 
somewhat  ruder  in  sound,  being  generally  designated  by  the  term 
moist  or  dry  crackling,  according  to  the  sensation  produced  upon 
the  ear.  This  constitutes  the  first  degree  of  a  phenomenon  which 
will  be  hereafter  considered,  called  gurgling  (gargouillemenf). 

The  mucous  rhonchus  consists  of  still  larger  bubbles,  which  are 
more  moist  and  ordinarily  more  unequal  than  the  preceding ;  it 
is  produced  by  the  passage  of  the  air  through  fluids  contained  in 
the  trachea  or  bronchi,  or  acccumulated  in  the  ulcerated  cavities 
which  succeed  tubercular  softening.  This  sound  is  similar  to  that 
heard  in  the  throats  of  dying  persons.  It  sometimes  exists  over  a 
large  extent  of  the  chest  in  those  affected  with  pulmonary  catarrh, 
and  is  always  confined  to  one  or  more  circumscribed  spots  t  in 
phthisis.  It  often  disappears  after  coughing,  from  the  displacement 
of  the  mucus  by  which  it  is  produced. 

In  some  diseases,  if  the  ear  be  applied  over  some  point  of  the 
chest,  a  sound  is  distinguished  analogous  to  that  produced  by  the 
agitation  of  a  liquid  mixed  with  air  bubbles.  This  phenomenon, 
which  in  its  lightest  form  may  be  easily  confounded  with  the  mu- 
cous and  subcrepitant  rhonchi,  but  which  is  easily  distinguishable 
from  these  when  strongly  marked,  has  been  termed  gurgling  or 
the  cavernous  rhonchus.  It  is  chiefly  heard  at  the  summit  of  the 
lungs,  and  is  a  certain  sign  of  cavities  arising  from  tubercular 

is  a  curious  fact,  mentioned  by  Hourmann  and  Dechambre,  that  in  old  persons 
the  babbles  which  produce  this  rhonchus  are  larger,  owing  to  the  increased  size 
of  the  pulmonary  cell,  caused  by  the  absorption  of  the  intercellular  tissue. 
—  TRANS. 


142  SYMPTOMS. 

softening.  It  may  also  exist,  though  more  rarely,  in  dilatation  of 
the  bronchi  and  in  the  cavities  produced  by  circumscribed  gangrene 
or  pulmonary  abscass,  but  generally  in  such  cases  so  differing  in 
situation  and  extent,  as  not  to  lead  to  error  in  the  diagnosis.  In 
order  to  the  production  of  this  sound,  the  cavity  should  not  only  be 
entirely  rilled  with  liquid,  but  in  extensive  communication  with 
the  bronchi.  It  is  chiefly  audible  when  the  patient  coughs,  or 
draws  a  full  and  deep  inspiration. 

Gurgling  is,  in  most  persons,  heard  over  a  circumscribed  and  lim- 
ited space,  one  or  two  inches  in  size,  for  example.  In  cases  where 
it  is  perceptible  over  a  greater  extern,  it  commonly  varies  in  inten- 
sity and  form,  at  different  points,  and  the  cause  of  this  is  easily 
explained ;  this  phenomenon  being  almost  always  produced  by  the 
agitation  of  air  with  a  liquid  in  ulcerated  cavities  following  tuber- 
cular softening,  and  these  cavities  being  often  numerous  and  vary- 
ing in  their  size  and  form,  in  the  quantity  and  consistence  of  the 
fluids  which  they  contain,  and  the  different  conditions  of  the  open- 
ing by  which  they  communicate  with  the  bronchial  tubes,  the 
sounds  resulting  from  this  agitation  must  vary  at  different  points 
within  a  short  distance  of  each  other. 

There  are,  however,  some  cases  in  which  a  manifest  gurgling 
is  distinctly  audible,  over  the  whole  of  one  side  of  the  chest,  together 
with  a  dull  sound  on  percussion,  the  gurgling  being  everywhere 
the  same  as  to  its  intensity  and  form.  The  diagnosis,  in  the  first 
case  of  this  kind  that  I  observed,  was  so  obscure,  that  I  hesitated 
in  giving  an  opinion.  The  patient  had,  at  first,  presented  all  the 
signs  of  a  considerable  pleuritic  effusion  ;  dull  sound,  absence  of 
respiratory  murmur  and  vocal  resonance,  together  with  dilatation  of 
the  diseased  side.  When  I  saw  him,  a  month  afterwards,  the  dull 
sound  still  continued  ;  but  to  the  ear,  applied  successively  in  front, 
behind,  above  and  below,  a  gurgling  sound  was  everywhere  dis- 
tinguishable, the  same  in  form  and  degree,  as  if  the  pulmonary 
tissue  had  been  entirely  transformed  into  a  multitude  of  ulcerated 
cavities,  alf  presenting  similar  phenomena,  and  consequently  ma- 
terial conditions  exactly  identical,  a  circumstance  which,  without 
being  strictly  impossible,  was  entirely  inadmissible.  This  young 
man  after  leaving  Paris  died  in  the  provinces;  no  examination 
after  death  was  made. 

I  again  observed  this  gurgling,  uniform  in  rhythm  and  intensity, 
together  with  a  dull  sound  on  percussion,  over  the  whole  of  one 
side  of  the  chest,  in  a  patient  at  La  Charite.  This  man  rejected 
by  the  mouth,  a  few  days  after  his  entrance  into  the  ward  St.  Jean 
de  Dieu,  more  than  a  pound  of  fetid  pus,  which  must  have  come 
from  the  cavity  of  the  pleura.  This  second  case  afforded  me  the 
explanation  of  the  former,  and  led  me  to  suppose  that  an  excava- 
tion formed  in  the  pulmonary  tissue,  opening  into  the  bronchial 
cavity,  and  situated  just  beneath  the  pleura,  the  cavity  of  which 
is  filled  with  pus,  may,  under  some  conditions  not  yet  with  cer- 
tainty determined,  if  a  thin  pellicle  alone  intervenes  between  the 
ulcerated  cavity  of  the  lungs  and  the  pus  contained  in  the  pleura, 


SYMPTOMS.  1 43 

or  if  there  exist  a  valvular  opening  preventing  the  passage  of  air 
into  the  pleura  and  the  production  of  pneumo thorax,  give  rise  to  a 
phenomenon  as  remarkable  as  that  observed  in  the  two  cases  just 
alluded  to.  The  gurgling  was  probably  produced,  as  it  ordinarily 
is,  in  the  tubercular  cavity,  and  thence  transmitted  to  the  whole 
periphery  of  the  chest  by  the  liquid  contained  in  the  pleura,  as, 
under  other  circumstances,  this  liquid  transmits  the  voice  (ego- 
phony),  and  the  respiratory  murmur  bronchial  respiration.* 

The  patient  last  alluded  to,  after  having  vomited  pus  in  abun- 
dance, and  at  various  times,  gradually  recovered  so  as  to  be  able 
to  leave  the  hospital.  I  advised  him,  should  the  symptoms  again 
present  themselves,  to  return.  He,  however,  finally  recovered,  at 
least  to  all  appearance.  This  case,  though  incomplete,  fixed  my 
opinion  upon  the  value  of  this  symptom,  which  I  believe  has  not 
before  been  pointed  out. 

A  third  case,  more  recently  observed  at  Hotel  Dieu,  gave 
farther  evidence  of  the  value  of  this  sign.  A  negro  who  was  ad- 
mitted into  the  ward  Sainte  Madeleine,  presented  symptoms  of 
pleuritic  effusion,  with  intense  fever:  to  these  phenomena,  was 
soon  added  a  gurgling  similar  to  that  which  occurred  in  the  two 
other  cases,  being  audible  over  the  whole  of  one  side  of  the  chest, 
and  everywhere  under  the  same  form  and  with  equal  intensity. 
A  few  days  after,  a  large  quantity  of  pus  was  rejected  by  the 
mouth.  After  the  death  of  the  patient,  we  were  able  to  ascertain 
with  certainty,  that  the  cavity  of  the  pleura  being  filled  with  pus, 
communicated  with  the  bronchi  by  means  of  a  tubercular  cavity. 
The  insufflation  of  air  into  the  trachea  showed  the  point  at  which 
the  pleura  was  perforated,  and  permitted  us  to  trace  the  nstulous 
track  to  one  of  the  bronchial  divisions. 

In  these  three  cases  only,  have  I  observed  this  form  of  gurgling 
with  the  conditions  described,  and  in  all  these  the  disease  com- 
menced in  the  same  manner,  by  a  pleuritic  effusion. 

I  have  twice  observed  a  form  of  gurgling  somewhat  analogous 
to  that  in  the  preceding  cases,  from  which  it  should  be  distin- 
guished. 

A  patient  was  admitted  to  the  Hotel  Dieu  for  a  chronic  affection 
of  the  chest,  who  presented,  independently  of  the  cough,  opaque 
sputa,  dyspnoea,  and  the  other  ordinary  phenomena  of  hectic  fever, 
a  dull  sound  over  the  whole  anterior  part  of  the  left  side  of  the 
chest.  At  whatever  point  of  this  portion  the  ear  was  applied, 
gurgling  was  audible ;  this  gurgling,  as  in  the  three  other  cases, 
was  everywhere  the  same  as  to  form,  but  its  intensity,  instead  of 

*  The  co-existence  of  a  pleuritic  effusion  with  tubercular  cavities  in  the  lungs 
is  by  no  means  rare,  although  the  kind  of  gurgling  which  I  have  pointed  out  has 
only  been  observed  in  a  very  few  cases  ;  it  is  necessary  then,  in  order  to  the 
production  of  this  phenomenon,  not  only  that  this  complication  exist,  but  that  it 
should  exist  under  peculiar  conditions,  without  which  it  could  not  take  place. 
This  phenomenon  appears  to  me  a  certain  sign  of  the  simultaneous  existence  of 
the  two  lesions  just  indicated  ;  but  iis  absence  by  no  means  proves  the  non-exis- 
tence of  this  complication. 


144  SYMPTOMS. 

being  the  same  wherever  the  dull  sound  existed,  progressively 
diminished  from  the  summit  of  the  thorax  where  it  was  f  ery  man- 
ifest, to  a  point  below  the  heart  where  it  became  obscured.  I  was 
led  to  suspect  in  this  patient  a  lesion  analogous  to  those  which  ex- 
isted in  the  three  others,  but  confined  to  the  anterior  part  of  the 
chest,  in  short,  a  partial  effusion  into  the  pleura  with  perforation 
of  the  pulmonary  parenchyma  about  to  take  place,  or  already 
completed.  The  exceeding  rareness,  however,  of  pleurisies  con- 
fined to  this  region,  and  the  progressive  diminution  in  the  gurgling 
sound  from  the  summit  towards  the  base,  caused  me  to  be  circum- 
spect in  the  diagnosis.  After  death,  we  found  at  the  summit  of 
the  left  lung,  a  collection  of  small  tubercular  cavities,  in  an  extent, 
of  the  size  of  a  pullet's  egg,  the  rest  of  the  anterior  portion  of  the 
pulmonary  parenchyma  being  indurated  and  presenting  a  grayish 
appearance.  In  this  case  the  gurgling  had  evidently  been  pro- 
duced in  the  ulcerated  cavities  at  the  summit  of  the  lung,  and  the 
sound  had  been  transmitted  by  the  indurated  lung,  and  in  the 
whole  extent  of  the  induration,  with  the  progressive  diminution  in 
intensity,  above  mentioned.  I  had  occasion  to  observe  in  another 
case,  under  analogous  anatomical  conditions,  the  same  phenome- 
non, but  less  marked  and  heard  over  a  less  extent. 

It  follows  from  these  cases  that  a  similar  sound,  heard  over  a 
great  extent,  or  over  the  whole  of  one  side  of  the  chest,  should  lead 
us  to  suspect  two  distinct  lesions,  the  one  which  gives  rise  to  the 
production,  the  other  to  the  transmission,  of  the  gurgling.  The  first, 
generally  consists  of  one  or  more  ulcerated  cavities  in  the  pulmo- 
nary parenchyma,  the  second,  in  induration  of  the  lung,  or  pleu- 
ritic effusion.  If  the  gurgling  be  perceptible  over  the  whole  of  one 
side  of  the  chest,  with  the  same  form  and  intensity,  its  transmis- 
sion depends  upon  a  pleuritic  effusion ;  it  is  owing  to  pulmonary 
induration,  if  the  sound,  the  same  as  to  its  form,  progressively  di- 
minishes in  intensity  over  the  extent  in  which  it  is  heard.  In  the 
latter  case,  the  transmission  is  almost  always  confined  to  a  part  of 
the  chest ;  in  the  former,  it  ordinarily  extends  over  its  whole  side. 

The  sonorous  rhonchus  is  a  dull  sound,  sometimes  extremely 
loud,  which  at  one  time  resembles  the  snoring  of  a  person  asleep, 
at  another,  the  base  note  of  a  violincello,  and  occasionally  the 
cooing  of  a  pigeon.  This  phenomenon  must  not  be  confounded 
with  the  guttural  sound  produced  by  some  persons  when  asleep, 
and  which  any  one  may  imitate  at  will.  The  latter  is  produced 
in  the  throat ;  that  which  we  are  now  considering,  proceeds 
from  the  chest,  and  is  only  perceptible  by  auscultation.  It  seems 
to  depend  upon  a  change  in  the  thickness  and  humidity  of  the 
bronchial  mucous  membrane. 

The  sibilant  rhonchus  commonly  resembles  a  prolonged  whistle, 
low  or  acute ;  sometimes,  the  chirping  of  small  birds,  the  sound  of 
a  pump,  or  the  clacking  of  a  valve.  It  appears  to  be  owing  to  a 
small  quantity  of  very  viscid  mucus  which  partially  fills  up  the 
bronchial  ramifications,  or  to  swelling  of  the  mucous  membrane. 
These  two  varieties  of  the  dry  rhonchus,  but  particularly  the 


0  SYMPTOMS.  145 

latter,  occur  in  acute  or  chronic  pulmonary  catarrh,  and  at  every 
period  of  the  disease.  These  rhonchi,  both  the  sibilant  and  sono- 
rous, are  heard  over  almost  the  whole  extent  of  the  chest  in  patients 
with  typhoid  fever ;  they  are  louder,  and  audible  over  a  greater 
extent,  than  in  bronchitis,  although  there  is  less  dyspnoea  than  in 
the  latter  affection. 

Independently  of  the  sound  perceptible  to  the  ear  in  the  various 
kinds  of  rhonchus,  there  sometimes  exists,  particularly  with  the 
sonorous  rhonchus,  a  sort  of  trembling,  perceptible  to  the  hand,  in 
that  portion  of  the  chest  corresponding  to  the  part  affected.  When 
the  lesion  which  produces  the  rhonchus  is  deeply  seated,  this 
trembling  is  not  so  distinct ;  the  absence  of  this  phenomenon  be- 
comes then  a  sign  which  may  aid  in  determining  the  particular 
seat  of  the  disease. 

There  is  another  variety  of  sound,  differing  from  the  rhonchus, 
which  may  be  distinguished  by  auscultation  during  the  respiratory 
movements,  and  still  more  easily  if  the  patient  speaks  or  coughs. 
This  sound,  called  by  Laennec  metallic  tinkling,  resembles  that 
emitted  by  a  plate  of  glass  or  metal  when  gently  struck  with  a  hard 
body.  This  phenomenon  has  only  been  observed  in  patients  with 
ulcerated  cavities  in  the  lungs  or  pleuritic  effusion.  In  both  cases, 
it  appears  indispensable  to  its  production,  that  the  cavity  contain 
a  liquid  together  with  air,  and  that  it  communicate  with  the  bron- 
chi. According  to  Laennec,  this  sound  is  produced  by  the  reso- 
nance of  air  agitated  at  the  surface  of  the  liquid,  or  the  falling 
of  a  drop  of  fluid  from  the  summit  of  the  cavity  into  the  fluid 
collected  in  the  under  part  of  it.  Other  physicians  (M.  M.  Dance 
and  Beau)  have  endeavored  to  explain  this  phenomenon  by  sup- 
posing that  in  the  act  of  speaking,  coughing  or  breathing,  air 
escapes  through  the  pulmonary  fistula  into  the  liquid  effusion, 
and  rises  to  its  surface  in  the  form  of  bubbles  of  a  greater  or  less 
size,  which,  in  breaking,  cause  a  vibration  in  the  air  above,  thus 
producing  the  resonance  which  constitutes  metallic  tinkling.  * 

*  However  satisfactory  the  explanations  which  have  hitherto  been  offered 
to  account  for  this  curious  phenomenon,  none  has  as  yet  been  found  to  hold  good 
in  all  cases. 

We  have  been  kindly  permitted  to  quote  two  cases  which  fell  under  the  observa- 
tion of  Dr.  J  D.  Fisher  of  this  city,  as  proving  the  truth  of  this  assertion,  and 
illustrative  of  the  ingenious  theory  proposed  by  him,  in  accounting  for  the  pro- 
duction of  this  sound. 

The  first  was  a  case  of  pneumothorax,  in  which  the  metallic  tinkling  was  heard 
in  its  maximum  intensity  over  the  right  scapula,  and  at  the  acme  of  each  respira- 
tion. Upon  examination,  a  communication  was  found  to  exist  between  the  bronchi 
and  cavity  of  the  pleura  by  means  of  a  small  opening,  almost  exactly  opposite  the 
point  where,  during  life,  the  sound  was  most  distinct,  and  far  above  the  level  of  the 
fluid  which  was  in  small  quantity  and  of  the  consistence  of  thick  cream.  Upon 
examining  this  opening,  it  was  found  to  be  covered  by  a  small  semi-circular  flap, 
apparently  formed  by  a  thin  lamina  of  the  pleura,  about  three  lines  in  diameter, 
and  which,  upon  blowing  into  the  trachea,  was  forced  open,  a  slight  click  being  at 
the  same  time  audible. 

The  second  case  was  that  of  a  large  cavity  in  the  lungs,  with  exceedingly  thin 
walls,  and  in  which  the  sound  was  also  heard  at  the  acme  of  respiration.  This 
13 


146  SYMPTOMS.  % 

Metallic  tinkling  is  not  always  the  same.  Thus,  when  it  takes 
place  in  a  cavity,  it  is  only  audible  over  a  circumscribed  space, 
while,  if  symptomatic  of  pulmonary  fistula  and  pneumothorax.  it 
is  heard  over  a  great  extent.  Laennec  remarks  that  this  phenom- 
ena is  more  appreciable,  when  the  fistula  is  large  and  the  quantity 
of  air  in  the  chest  very  considerable. 

The  metallic  tinkling  generally  coincides  or  alternates  with  am- 
phoric respiration.  Great  respiratory  efforts  render  them  more 
manifest,  and  may  reproduce  them  when  not  permanent. 

There  is  still  another  phenomenon  which  we  shall  point  out,  not 
without  importance  as  a  diagnostic  and  prognostic  sign  ;  we  refer  to 
thoracic  succussion,  a  method  of  exploration  employed  by  Hippo- 
crates, and  clearly  pointed  out  in  his  works,  but  the  semeiological 
value  of  which  he  did  not  fully  appreciate.  This  method  consists 
in  forcibly  shaking  the  patient's  chest,  while  the  ear  is  placed  near 
this  cavity :  the  sound  of  fluctuation  is  then  distinctly  heard,  some- 
times extending  to  the  assistants  at  a  distance,  and  the  patients 

sound  was  produced  after  the  death  of  the  patient,  by  blowing  through  the  trachea. 
In  this  case,  as  in  the  other,  the  cavity  was  found  to  contain  but  little  fluid,  and 
the  bronchial  opening,  which  was  of  considerable  size,  existed  above  its  level,  its 
truncated  portion  being  remarkably  smooth.  This  opening  was  only  discoverable 
by  blowing  into  the  trachea,  when,  as  the  air  passed  into  the  cavity,  the  walls, 
which  were  previously  in  close  contact,  and,  as  it  were,  glued  together  by  the 
viscid  secretion  of  the  part,  were  seen  suddenly  to  separate  with  a  sound  almost 
precisely  similar  to  that  produced  during  life. 

It  would  appear  then  that,  at  least,  in  these  two  cases,  the  principal  condition 
necessary  to  the  production  of  the  metallic  tinkling,  according  to  the  theory  of 
Dance  and  Beau,  and  the  experiments  of  Fourriet,  Bigelow  and  others,  viz.  the 
existence  of  an  opening  below  the  surface  of  the  fluid,  was  absent.  The  theory 
of  Laennec  would  also  seem,  in  these  cases,  insufficient  to  explain  this  phenome- 
non, as  the  sound  occurred  at  regular  intervals  with  each  respiration,  the  patient 
being  in  a  state  of  rest. 

In  order  to  the  farther  elucidation  of  this  point,  Dr.  Fisher  made  the  following 
experiment,  which  seems  fully  to  confirm  the  views  which  he  had  previously  enter- 
tained. 

Having  inserted  an  elastic  flexible  tube  into  the  neck  of  a  distended  bladder, 
upon  blowing  into  it,  the  amphoric  resonance  was  distinctly  heard.  He  now  poured 
a  thick  solution  of  gum  arable  into  the  tube,  to  render  the  conditions,  as  nearly  as 
possible,  similar  to  those  in  the  above  mentioned  cases,  when  upon  again  blowing 
into  it,  a  click  exactly  resembling  the  metallic  tinkling  was  distinctly  heard. 

He  concluded,  from  these  observations  and  experiments,  that  if  an  unobstructed 
opening  into  a  large  cavity,  exist,  amphoric  resonance  will  be  produced,  while  if 
there  be,  in  this  opening,  any  impediment  to  the  passage  of  the  air,  as  viscid  mu- 
cus, or,  as  in  the  first  case,  a  valvular  formation,  which  suddenly  yields,  the  me- 
tallic tinkling  is  the  result. 

The  following,  then,  are  the  conditions  which,  according  to  Dr.  Fisher,  are 
necessary  to  the  production  of  this  sound;  1,  a  cavity  of  considerable  size  with 
thin  walls;  2,  a  communication  between  this  cavity  and  the  bronchia,  by  an  open- 
ing in  which  there  exists  some  obstruction  which  suddenly  yields  to  the  force  of 
the  air. 

Without  denying  the  possibility  of  the  occurrence  of  this  sound  under  the  con- 
ditions hitherto  considered  necessary  to  its  production,  it  must  be  admitted  that 
there  are  cases  in  which  these  conditions  entirely  fail,  and  in  which  some  other 
explanation  must  be  sought.  The  theory  proposed  by  Dr.  Fisher  affords  a  satis- 
factory explanation  of  this  sound  in  cases  which  are  inexplicable  by  any  other,  and 
may  be  found  to  account  for  its  production  in  nearly  all  cases.  —  TRANS. 


SYMPTOMS.  147 

themselves  often  perceiving  it  when  executing  any  movement,  as 
descending  a  staircase,  examples  of  which  are  related  by  Ambrose 
Pare,  Willis,  Morgagni,  Boyer,  &c.*  This  sound,  regarded  by 
Hippocrates  as  a  sign  of  serous  effusion  in  the  chest,  is  never 
heard  in  simple  hydrothorax  ;  it  only  occurs  in  cases  in  which  the 
pleura  contains  liquid  and  air  together,  and  is  sometimes  produced 
when  an  enormous  hollow  cavity  in  the  lungs  exists.  As  we  have 
seen,  metallic  tinkling,  amphoric  respiration  arid  the  hippocratic 
fluctuation,  are  phenomena  equally  characteristic  of  a  determinate 
alteration ;  wherever  any  one  of  these  exist,  the  prognosis  must  be 
grave,  since  it  reveals  the  existence  of  pathological  conditions 
almost  necessarily  fatal. 

Thoracic  fluctuation  should  not  be  confounded  with  an  analo- 
gous sound  sometimes  produced  in  the  stomach  when  the  body  is 
shaken,  the  stomachal  gurgling  which  has  been  before  alluded  to  : 
it  is  sufficient  to  be  warned  of  this  error  in  order  to  guard  against 
it. 

Independently  of  these  sounds  that  we  have  just  considered, 
and  all  of  which  are  owing  to  the  passage  of  air  into  the  natural 
or  accidental  cavities,  there  is  another  which  depends  upon  the 
friction  of  serous  surfaces  against  each  other.  This  sound  has 
been  described  by  Laennec,  under  the  term,  ascending  and  de- 
scending murmur  (murmur  ascensionis  et  descensionis). 

But  Dr.  Reynaud  was  the  first  who  thoroughly  investigated 
the  anatomical  conditions  which  give  rise  to  this  sound  and  as- 
certained its  true  value  as  a  'diagnostic  sign.  In  the  ordinary  act 
of  respiration,  during  the  alternate  movements  of  elevation  and 
depression  of  the  thoracic  parietes,  there  is  a  rubbing  of  the  pul- 
monary against  the  costal  pleura ;  but  owing  to  the  smoothness 
and  moisture  of  these  surfaces,  no  sound  is  probably  produced,  or 
if  it  exist,  it  is  confounded  with  the  natural  murmur  of  respiration. 
But  when  more  or  less  roughness  or  inequality  exists,  produced  by 
false  membranes  adherent  to  the  surface  of  the  pleurae,  a  rough 
friction  sound,  like  that  of  rumpled  parchment,  a  file,  or  new  leather, 
accompanying  both  respiratory  movements,  but  particularly  that 
of  inspiration,  is  audible  at  a  point  corresponding  to  this  lesion. 
In  some  cases,  by  applying  the  hand  over  this  part,  a  peculiar 
and  characteristic  tremor  is  perceived.  The  friction  sound  may 
occur  at  the  commencement  of  dry  pleurisy,  or  towards  the  termi- 
nation of  pleurisy  with  effusion,  when,  in  consequence  of  the 
reabsorption  of  the  fluid,  the  two  opposite  surfaces  of  the  pleura, 
covered  with  false  membranes,  come  in  contact.  Laennec  was 
probably  wrong  in  attributing  the  ascending  and  descending  fric- 
tion sounds  to  interlobular  emphysema  of  the  lungs. 

-Besides  these  phenomena  furnished  by  means  of  thoracic  aus- 
culation,  there  are  others  occurring  in  rare  diseases,  that  have 
not  yet  been  observed  since  this  mode  of  exploration  became 
known,  which  it  cannot  fail  to  reveal. 

*  Laennec,  torn.  ii.  p.  587  ;  4e  edition. 


148  SYMPTOMS. 

In  hernia  of  the  lungs  through  the  intercostal  muscles,  for  ex- 
ample, the  application  of  the  stethoscope  over  the  tumor  would 
undoubtedly  enable  us  to  hear  the  entrance  and  egress  of  the  air, 
thereby  adding  a  new  sign  to  the  diagnosis  of  this  affection.  In 
cases  in  which  borborygmi  are  audible  above  the  region  of  the  stom- 
ach, the  existence  of  hernia  of  the  stomach  or  intestines  through 
the  diaphragm,  might,  according  to  Laennec,  be  safely  inferred. 
This  certainty,  however,  cannot  exist  until  an  assertion,  which  is 
probable,  but  the  truth  of  which  is  not  yet  demonstrated,  shall 
have  been  confirmed  by  experience.  The  varieties  presented  in 
the  concavity  of  the  diaphragm,  and  those  which  exist,  conse- 
quently, in  the  position  of  the  stomach,  the  facility  with  which 
sounds  are  transmitted  to  a  certain  distance,  the  peculiar  noise  pro- 
duced by  the  rising  of  the  air  from  the  stomach  into  the  oesopha- 
gus, appear  to  us  to  justify  the  doubts  that  we  have  entertained  in 
respect  to  the  pathognomonic  value  of  this  phenomenon. 

Auscultation  of  the  voice  furnishes  the  diagnosis  of  thoracic  dis- 
eases with  certain  phenomena  interesting  to  the  observer,  and 
very  useful  in  a  diagnostic  point  of  view.  When  a  healthy  man 
speaks  or  sings,  his  voice  generally  produces  over  the  whole  extent 
of  the  thoracic  parietes  a  kind  of  vibration  perceptible  to  the  hand. 
If  the  ear,  or  stethoscope,  be  applied  to  the  chest,  this  vibration  is 
less  apparent  ;  but  a  remarkable  resonance  is  observed,  particularly 
in  those  regions  where  the  soft  parts  are  thinnest,  or  those  corres- 
ponding to  the  larger  bronchi  more  or  less  superficially  situated. 
Thus,  this  vocal  resonance  is  particularly  apparent  in  the  axillae,  in 
the  superior  and  anterior  regions  of  the  chest,  in  the  interscapular 
space,  and  at  the  superior  and  internal  angles  of  the  scapulae,  partic- 
ularly the  right,  the  lung  of  that  side  being  more  voluminous  and 
the  bronchus  larger.  This  natural  resonance  of  the  voice  is  want- 
ing in  some  persons  ;  in  others,  it  is  hardly  perceptible  ;  it  is  par- 
ticularly observed  in  those  who  have  a  deep,  sonorous  voice,  and 
full  chest.  In  disease,  this  resonance  undergoes  important  modi- 
fications ;  it  may  be  diminished,  completely  cease,  or  be  replaced 
by  other  phenomena,  known  as  bronchophony,  aegophony  and 
pectoriloquy. 

The  natural  vibration  of  the  thoracic  walls  is  generally  dimin- 
ished in  hepatization  of  the  lungs  ;  it  entirely  ceases  in  cases  of 
pleuritic  effusion,  so  that  it  is  sometimes  possible  to  mark  exactly 
the  level  of  the  liquid  by  the  point  where  the  resonance  begins  to 
be  again  perceptible  ;  but  this  phenomenon  is  of  far  less  importance 
than  those  we  are  about  to  consider. 

Bronchophony  *  is  a  resonance  of  the  voice  more  or  less  loud  and 
diffused,  an  accurate  idea  of  which  may  be  obtained  by  applying 
the  stethoscope  over  the  larynx  of  a  person  while  speaking.  In 
disease,  this  phenomenon  is  produced  under  the  same  anatomical 


bronchus  ;  (pwvrj,  voice.  In  accordance  with  Greek  etymology  it 
should  be  written  broncophony  ;  but  we  have  thought  that  the  word  created  by 
Laennec,  and  accepted  by  science  should  be  preserved  ;  besides,  the  terms  bronchi, 
bronchial,  are  employed. 


SYMPTOMS.  1 49 

conditions  which  give  rise  to  tnbal  or  bronchial  respiration,  that  is, 
in  red  and  gray  hepatization  of  the  lungs,  pleuritic  effusions,  and 
pulmonary  induration  produced  by  tubercular  matter,  melanosis, 
&c.  When  broncophony  and  tubal  respiration  depend  upon  dis- 
ease of  the  parenchyma  of  the  lungs,  these  sounds  remain  the  same 
in  whatever  position  the  patient  be  placed.  If,  on  the  contrary, 
they  are  owing  to  effusion,  by  placing  the  patient  in  different  posi- 
tions, these  phenomena  are  rendered  more  marked',  or  more  obscure, 
and  the  point  where  they  are  produced,  if  nothing  oppose  the  fall- 
ing of  the  fluid  in  obedience  to  the  laws  of  gravity,  may  become 
changed.  Now,  observation  shows  that  this  is  far  from  common, 
and  that  in  most  cases,  in  which  the  effusion  has  existed  but  a  few 
days,  the  liquid  remains  within  the  same  limits,  whatever  be  the 
attitude  of  the  patient.  In  regard  to  the  theory  of  bronchophony, 
Laennec  thought  that  it  resulted  from  impermeability  of  the  air 
cells  and  ultimate  bronchial  ramifications,  and  the  consequent 
resonance  of  the  voice  in  the  large  bronchial  tubes.  The  explana- 
tion of  this,  as  of  other  phenomena,  is  a  secondary  consideration. 
The  phenomenon  itself  and  its  semeiological  value  are  important 
points,  which  happily  are  understood. 

^Egophony,  *  like  bronchophony,  consists  in  increased  resonance 
of  the  voice,  but  presenting  different  characteristics.  This  reso- 
nance is  sharp,  trembling,  or  broken,  like  that  of  a  goat,  and 
seems  more  like  the  echo  of  the  patient's  voice,  than  the  voice 
itself.  If  this  phenomenon  occur  in  a  part  adjacent  to  a  large 
bronchial  trunk,  towards  the  root  of  the  lung  for  example,  in  addi- 
tion to  a  remarkable  resonance,  and  under  the  influence  of  these 
two  conditions  united,  the  voice  presents  modifications,  resembling 
that  produced  by  a  counter  placed  between  the  teeth  and  lips  of  a 
person  while  speaking,  or  bredouillement*  which  constitutes  the 
language  of  Punchinello.  /Egophony  may  be  perceptible  in  nearly 
all  parts  of  the  chest;  but  it  is  heard  particularly  between  the 
spine  and  scapulae,  around  the  latter  bones,  and  in  a  zone  two  or 
three  inches  wide,  extending  between  the  scapula  and  nipple.  It 
is  sometimes  distinguishable  on  the  first  day ;  it  however  becomes 
more  marked  in  the  few  days  following,  and  afterwards  disappears, 
the  effusion  being  either  absorbed  or  increased.  This  phenomenon, 
may,  like  bronchophony,  become  obscure,  disappear,  or  change  its 
place  according  to  the  position  of  the  patient,  if  adhesions  do  not 
prevent  displacement  of  the  fluid. 

Laennec  ingeniously  explained  the  phenomenon  of  segophony. 
by  supposing  it  to  be  produced  by  the  vibration  of  the  voice, 
transmitted  through  a  thin  and  trembling  layer  of  fluid.  The 
same  author  also  remarked  that  a  pleuritic  effusion  by  compres- 
sing the  bronchial  tubes,  flattens  them  like  the  mouthpiece  of  a 

*./fi£,  atyog,  goat;  tfmvih  voice. 

f  A  precipitate  and  indistinct  mode  of  utterance,  in  which  a  part  of  the 
words  only  is  pronounced,  and  several  of  the  syllables  viciously  changed.  It  is 
analogous  to  stuttering  in  some  respects.  —  TR. 

13* 


150  SYMPTOMS. 

bassoon  or  hautboy,  instruments  which  produce  a  bleating  sound. 
The  false  membranes  which  sometimes  cover  the  surface  of  the 
pleura,  have  also  been  supposed  to  give  rise  to  the  same  phe- 
nomenon. 

Whatever  be  its  explanation,  we  cannot  grant  to  this  phenomena 
all  the  importance  attributed  to  it  by  Laennec,  and  consider  it  as 
a  pathognomonic  sign  of  pleuritic  effusion ;  for,  on  the  one  hand, 
there  are  many  healthy  persons  in  whom  aegophony  exists, 
as  Laennec  himself  admits ;  and  on  the  other,  it  has  been 
noticed  in  cases  of  hepatization  of  the  lungs,  as  has  bronchophony 
in  some  cases  of  pleuritic  effusion.  If,  however,  aegophony  be 
not  pathognomic  of  effusion,  it  should  certainly  lead  us  to  suspect 
its  existence.  It  is  sometimes  difficult  to  distinguish  between 
segophony  and  bronchophony ;  they  often  exist  together,  a  circum- 
stance which  has  led  to  the  term  broncho-aegophony. 

Pectoriloquy*  consists  in  a  peculiar  resonance  of  the  voice, 
which,  in  mediate  auscultation,  seems  to  issue  directly  from  the 
chest  of  the  patient,  and  pass  through  the  central  canal  of  the 
stethoscope;  if  the  physician  employ  immediate  auscultation,  it 
appears  as  if  the  patient  were  speaking  in  his  ear. 

Laennec  distinguishes  several  varieties  of  pectoriloquy,  which 
he  severally  terms  perfect,  imperfect,  and  doubtful.  The  first  is 
alone  of  any  real  value.  The  two  others,  rather  resemble  bron- 
chophony, or  the  ordinary  resonance  of  the  voice.  They  may  be 
distinguishable,  in  the  healthy  state,  in  certain  parts  of  the  chest, 
particularly  at  the  summit,  and  as  far  as  nearly  to  the  third  rib. 
But  that  circumscribed  and  distinct  resonance  of  the  voice,  which 
constitutes  pectoriloquy,  should  be  considered  as  pathognomonic 
of  a  hollow  cavity  in  the  lungs,  whether  it  be  owing  to  a  simple 
dilatation  of  a  bronchus,  partial  suppuration  of  the  lungs,  or,  as 
generally  happens,  to  tubercular  softening. 

In  order  to  the  occurrence  of  pectoriloquy,  the  existence  of  a 
well  defined  superficial  hollow  cavity  in  the  lungs,  of  medium 
size,  that  of  a  nut  or  small  gullet's  egg,  for  example,  with  hard- 
ened walls,  is  necessary  ;  the  cavity  should  be  empty  and  commu- 
nicate freely  with  the  bronchi ;  there  must  be  absence  of  aphonia, 
which  is  a  frequent  symptom  in  the  last  stage  of  phthisis,  as  if 
this  exist,  pectoriliquy  cannot  be  produced.  The  phenomenon 
fails,  or  is  less  perfect,  if  the  cavity  be  filled  with  a  liquid,  be 
too  large  or  irregular  in  its  shape,  and  communicate  with  the 
bronchi  by  means  of  small  openings  alone,  which  are  not  in  pro- 
portion to  the  size  of  the  cavity.  In  general,  pectoriloquy  is  more 
apparent  when  the  voice  is  sharp,  than  when  low  or  hoarse.  This 
phenomenon  disappears  and  returns  alternately  in  some  persons  : 
this  intermittence  is  generally  owing  to  the  transient  occlusion  of 
the  cavities  or  of  the  bronchial  tube  which  communicate  with  it. 
Gurgling  often  accompanies  pectoriloquy,  and  adds  to  its  value  as 
a  sign. 

*  YrorapectuSj  breast ;  loqui,  to  speak, 


SYMPTOMS.  151 

Percussion,  as  well  as  auscultation  of  the  chest,  furnishes  many 
important  signs,  which  we  shall  now  proceed  successively  to  con- 
sider. 

In  disease,  the  sound  of  the  chest,  on  percussion,  may  be  clearer 
than  natural,  more  dull,  or  entirely  flat.  The  sound  becomes  clearer 
whenever  the  quantity  of  air  in  the  chest  becomes  increased,  and  the 
nearer  this  fluid  is  to  the  point  percussed  ;  this  is  the  case  in  pneu- 
mothorax  and  pulmonary  emphysema.  In  the  first  of  these  affec- 
tions the  chest  sounds  like  a  drum  over  a  greater  or  less  portion  of 
its  extent ;  in  emphysema  the  sound  is  less  clear  in  pneumotho- 
rax,  but  clearer  than  in  the  healthy  state.  In  both  affections,  the 
clear  sound  may  be  confined  to  a  limited  space,  or  it  may  extend 
over  the  whole  of  one  side  in  pnenmothorax,  and  over  both  in 
emphysema.  In  one  of  these  diseases  the  excess  of  resonance  is 
owing  to  the  presence  of  air  in  the  pleura ;  in  the  other,  to  its 
accumulation  in  the  dilated  pulmonary  vesicles.  A  sound  clearer 
than  natural  may  also  be  elicited,  when  percussion  is  practised 
over  a  large  empty  cavity  superficially  situated.  If  the  cavity 
be  partially  filled  with  a  fluid,  and  the  thoracic  walls  be  thin  and 
elastic,  the  sound  on  percussion  is  that  called  by  Laennec  le  bruit 
de  pot  fele,  the  sound  of  the  cracked  pot,  in  which  the  resonance 
of  a  cavity  with  gurgling  is  distinguished.  This  has  as  yet  never 
been  observed  except  in  phthisical  patients,  just  beneath  one  of  the 
clavicles. 

The  sound  of  the  chest  becomes  obscure  or  dull,  whenever  the 
lung  is  indurated,  or  when  a  solid  or  liquid  body  interposes  be- 
tween this  viscus  and  the  thoracic  parietes  at  the  point  percussed. 
The  sound  of  the  chest  is  slightly  diminished  in  pulmonary  con- 
gestion, the  first  stage  of  pneumonia,  and  some  cases  of  tubercles 
before  becoming  united  into  a  compact  mass,  and  in  slight  effu- 
sions of  liquid.  It  is  completly  flat  (tanquam  percussi  femoris)  in 
all  cases  of  pulmonary  induration,  in  rare  cases  of  tumors  within 
the  chest,  and  finally,  in  liquid  effusions  so  abundant  as  to  press  the 
lungs  backward  towards  the  vertebral  column.  In  the  latter  case, 
by  varying  the  position  of  the  patient,  it  might  be  possible  to  alter 
the  results  of  percussion,  if  the  effusion  were  partial,  and  there 
were  nothing  to  prevent  the  fluid  from  obeying  the  laws  of  gravity. 
Nothing  of  this  kind  is  observed  when  the  dull  sound  is  owing  to 
pulmonary  induration,  or  the  presence  of  a  tumor. 

In  enumerating  the  causes  which  produce  a  dull  or  obscure 
sound  of  the  chest  on  percussion,  we  have  not  referred  to  the 
adhesions  of  the  costal  with  the  pulmonary  pleura,  as,  in  our 
opinion,  they  have  no  part  in  producing  this  effect.  To  be  con- 
vinced of  this,  it  will  be  sufficient  to  recall  those  cases  of  phthisis, 
in  which  the  chest  sounds  clear  over  almost  its  whole  extent, 
although  the  adhesions  are  stronger,  and  a  more  constant  symptom 
in  this  than  in  any  other  disease.  Adhesions  do  not  affect  the 
resonance  of  the  chest,  unless  there  be  serous  or  gelatinous  infil- 
tration into  the  cellular  network  of  which  they  are  composed. 

Whenever  the  sound  elicited  by  percussion  is  flat  or  even 


152  SYMPTOMS. 

obscure,  that  peculiar  elasticity  which  is  always  felt  in  percussing 
a  healthy  chest,  is  no  longer  perceptible.  There  is,  on  the  con- 
trary, a  feeling  of  hardness  or  resistance,  which  is  in  proportion  to 
the  density  of  the  body  producing  the  dullness. 

The  rules  relating  to  the  employment  of  auscultation  and  per- 
cussion, together  with  the  semeiological  value  of  the  phenomena 
furnished  by  these  two  important  methods  of  exploration,  will  be 
considered  in  the  chapter  on  diagnosis. 

$  II.  Respiratory  phenomena.  Having  now  presented  the  prin- 
cipal symptoms  furnished  by  the  respiration  itself,  we  shall  pro- 
ceed briefly  to  consider  some  of  the  respiratory  phenomena,  as 
laughing,  yawning,  sneezing,  hiccough,  coughing,  exspuition,  and 
expectoration. 

1.  Laughing  (risus)  consists  in  an  interrupted  expiration,  ac- 
companied with  a  cheerful  expression  of  the  features,  and  partic- 
ularly retraction  of  the  lips.     This  is  a  phenomenon  peculiar  to 
health,  rather  than  a  symptom  of  disease.     There  are,  however, 
many  affections  in  which  it  occurs  under  the  latter  form,  depending 
either  upon  the  state  of  the  mind,  as  in  the  delirium  of  acute  dis- 
eases and  certain  forms  of  mental  alienation,  or  upon  a  special 
derangement  of  the  nervous  system,  as  in  hysteria,  and,  as  some 
have  asserted,  in  wounds  and  inflammation  of  the  diaphragm. 

2.  In  yawning  (oscitatio)  there  is  suddenly  a  deep,  slow,   and 
sonorous  inspiration,  with  separation  of  the  jaws,  and  accompan- 
ied with  flexion,  followed  by  the  slow  and  gradual  extension  of 
the  limbs,   and  particularly  the  arms.      This  latter  movement, 
called  pandiculation  (pandiculatio)   sometimes  occurs  without  the 
yawning,   which    it  almost    always    accompanies.      Both   these 
symptoms  frequently  appear  at  the  commencement  of  the  parox- 
ysms in  intermittent  fever,  and  towards  the  close  of  an  hysterical 
attack. 

3.  Sneezing  (sternutatio)  consists  in  a  violent  and  convulsive 
expiration,  by  which  the  air  is  driven  rapidly,  and  rushes  sonor- 
ously, through  the  nasal  fossae,  carrying  with  it  the  mucus  adher- 
ing to  these  parts.  Sneezing,  although,  like  yawning  and  stretching, 
occurring  in  health,  is  a  frequent  symptom  in  coryza,  and  in  the 
first  period  of  rubeola. 

4.  Hiccough  (singultus)  is  the  result  of  a  sudden  and  involun- 
tary contraction  of  the  diaphragm,  accompanied  with  contraction 
of  the  glottis  which  prevents  the  entrance  of  air  into  the  trachea. 
This   symptom  occurs  under  various  circumstances,  as  in   the 
lightest  affections,  and  even  in  persons  in  perfect  health,  and  in 
very  grave  diseases,  as,  abdominal  inflammation,  and  particularly 
peritonitis,  strangulated  hernia,  and  all  cases  of  stoppage  in  the 
course   of  faecal   matters,   in  which  its  appearance  confirms  the 
diagnosis,  and  renders  the  prognosis  more  unfavorable. 

5.  The  cough,  (tussis)  according  to  physiologists,  consists  in 
violent,  short,  and  frequent  expirations,  in  which  the  expired  air, 
in  passing  through  the  larynx,  produces  a  peculiar  sound.     This 
is  not  a  correct  definition.     One  of  the  most  constant  phenomena 


SYMPTOMS.  ,  153 

accompanying  coughing  is  a  momentary  occlusion,  or  at  least,  a 
considerable  contraction,  of  the  glottis.  This  contraction  does  not 
concur  alone  in  the  production  of  the  peculiar  sound  observed ;  it 
prevents  the  egress  of  air,  which  afterwards  escapes  with  great 
rapidity,  thus  more  easily,  by  communicating  to  it  the  impulse 
which  it  receives,  carrying  with  it  the  mucus  adherent  to  the 
parts  in  its  course. 

Many  varieties  of  cough  have  been  admitted,  of  which  the 
principal  are  the  idiopathic  *.  and  sympathetic,  moist  and  dry 
cough.  If  the  exciting  cause  of  the  cough  be  seated  in  any  of 
the  air  passages,  it  is  idiopathic  :  it  is  called  sympathetic  when  it 
depends  upon  an  affection  of  some  viscus  more  or  less  remote. 
The  idiopathic  cough  may  be  guttural  or  pectoral,  according  as  the 
irritation  which  excites  it,  is  above  or  below  the  glottis.  The 
sympathetic  also  varies  with  the  organ  which  causes  it.  That 
arising  from  an  affection  of  the  stomach,  has  been  called  stomachal 
cough  :  it  is  said  to  be  dry,  to  increase  after  a  meal,  to  be  accom- 
panied with  epigastric  pain,  nausea,  and  retching,  and  to  be  unaf- 
fected by  cough  medicines  and  mucilaginous  preparations,  but  to 
yield  to  acid  drinks,  emetics,  and  spontaneous  vomiting.  A  vermin- 
ous cough  has  been  admitted,  supposed  to  be  connected  with  the 
presence  of  worms  in  the  digestive  canal,  and  which  their  expulsion 
will  alone  remedy.  Certain  diseases  of  the  liver  give  rise  to  a  cough 
called  hepatic.  A  similar  effect  has  been  known  to  follow  certain 
affections  of  the  uterus.  Dahaen  relates  the  case  of  a  woman, 
who  was,  for  a  long  time,  affected  with  continual  coughing,  and 
who  was  not  relieved  of  this  troublesome  symptom,  until  the  spon- 
taneous expulsion  of  a  fibrous  tumor  from  the  uterus. 

The  moist  cough  (tussis  humidd)  is  that  which  excites  a  more 
or  less  abundant  excretion  of  mucus  by  the  mouth ;  in  the  dry 
cough  (tussis  siccd)  there  is  no  excretion.  xln  most  cases,  the 
cough  occurs  but  once  or  twice  in  succession,  then  ceasing,  to  re- 
turn again  at  a  more  or  less  remote  period.  When  the  cough  is 
both  dry  and  obstinate,  the  term  ferine  has  been  applied  to  it 
(tussis  ferind).  In  many  diseases,  it  occurs  rapidly  many  times, 
so  that  a  single  inspiration  is  followed  by  five  or  six  successive 
expirations,  constituting  paroxysms  of  coughing  (tussis  accessus). 
It  is,  in  such  cases,  accompanied  with  redness'of  the  face,  watery 
eyes,  headache,  tinnitus  aurium,  fullness  of  the  cervical  veins, 
retching,  and  sometimes  vomiting,  as  -is  noticed  in  pertussis, 
phthisis  pulmonalis,  and  some  varieties  of  bronchial  catarrh. 
Finally,  the  cough,  in  certain  affections,  presents  a  peculiar  tone 
and  rhythm  easily  distinguishable,  but  difficult  to  describe.  Thus 

*  The  word  idiopathic  has  been  generally  employed  as  synonymous  with 
essential,  and  applied  to  diseases  rather  than  symptoms.  But  this  word  being 
evidently  the  opposite  of  sympathetic,  and  it  being  impossible,  in  the  present 
state  of  the  science,  to  apply  the  latter  word  to  a  disease,  we  have  thought  it 
more  proper  to  apply  these  two  words  to  symptoms,  reserving  for  disease  the 
words  essential  and  symptomatic,  these  alone  being  suitable  to  the  present  state 
and  deficiencies  of  the  science. 


154  SYMPTOMS. 

in  the  last  stage  of  phthisis,  when  the  lung  has  become  filled  with 
numerous  and  large  cavities,  the  cough  has  a  peculiarly  hollow 
sound ;  in  laryngeal  phthisis  the  cough  is  low,  hoarse,  broken  and 
rough.  In  croup,  it  is  said  to  resemble  the  bark  of  the  dog,  the 
howling  of  the  fox,  the  crowing  of  the  cock,  &c.  Nothing  precise 
is  indicated  by  these  terms  of  comparison. 

The  exploration  of  the  cough  by  auscultation,  furnishes  some 
remarkable  phenomena.  The  various  kinds  of  rhonchus  are  gen- 
erally more  marked  during  coughing  than  during  respiration :  thus 
in  incipient  penurnonia  and  in  the  same  disease  when  on  the  de- 
cline, the  crepitant  rhonchus  is  often  imperceptible,  except  during 
cough,  or  the  full  inspiration  which  follows  it.  In  phthisical  pa- 
tients, if  the  ear  be  applied  over  the  ulcerated  cavities,  a  gurgling 
is  sometimes  distinguished  during  the  cough,  which  is  entirely 
imperceptible  in  the  ordinary  movements  of  respiration.  In  some 
cases,  instead  of  the  gurgling,  the  fluctuation  of  a  liquid  is  audible ; 
this  sound  is  similar  to  that  produced  by  emptying  a  bottle  of  the 
liquid  it  contains. 

Exspuition  (expuitio)  is  the  act  by  which  the  matters  accumu- 
lated in  the  pharynx  are  rejected  :  it  is  by  means  of  the  guttural 
cough,  that  exspuition  is  effected.  The  mucus  of  the  posterior 
part  of  the  nasal  fossae,  which  is  carried  back  into  the  throat  by  a 
peculiar  inspiratory  effort,  a  sort  of  snuffing,  that  of  the  bronchi, 
which  is  forced  up  into  the  pharynx  by  the  pectoral  cough,  are 
both  rejected  in  the  act  of  exspuition. 

Expectoration  (expectoratio),  a  term  which  has  been  improperly 
applied  to  the  expectorated  matter,  is  the  act  by  which  matters 
contained  in  the  trachea,  and  particularly  the  bronchi,  are  expelled 
from  them.  This  occurs  in  three  different  ways :  1.  When  the 
bronchi  contain  but  a  moderate  quantity  of  sputa,  they  are  forced 
by  the  pectoral  cough  into  the  pharynx,  thence  into  the  mouth, 
and  are  finally  rejected.  2.  In  cases  in  which  a  great  quantity  of 
liquid  is  suddenly  or  rapidly  poured  into  the  bronchi,  as  in  certain 
cases  of  haemoptysis,  or  the  rupture  of  an  aneurismal  cyst  or 
pleural  abscess  into  the  air  passages,  the  expectoration  resembles 
vomiting;  the  lungs,  strongly  compressed  by  an  almost- convulsive 
contraction  of  the  expiratory  muscles,  transmit  this  compression 
to  the  bronchi;  the  liquid  with  which  they  are  filled  escapes 
through  .the  glottis,  and  issues  in  abundance  from  the  mouth,  and 
sometimes  from  the  nose:  this  is  a  kind  of  pectoral  vomiting;  in 
such  cases  the  patient  is  often  said,  both  by  the  physician  and 
others,  to  have  vomited  blood  or  pus.  In  nursing  infants  and  chil- 
dren previous  to  the  fifth  or  sixth  year  of  age,  expectoration  rarely 
occurs  in  any  other  way.  At  this  age,  the  sputa  are  generally 
expelled  by  pectoral  vomiting  which  follows  the  efforts  to  cough  : 
in  other  cases,  after  being  forced  into  the  pharynx  by  the  pectoral 
cough,  they  are  carried  by  deglutition  into  the  stomach,  whence 
they  pass  into  the  intestines  or  are  rejected  by  vomiting,  properly 
so  called.  3.  In  other  cases,  in  which  the  quantity  of  fluid  exhaleci 
is  small  in  quantity,  it  sometimes  happens  that  this  liquid  rises 


SYMPTOMS.  155 

0 

gradually  into  the  larynx  and  even  the  pharynx,  without  exciting 
any  cough,  and  is  expelled  by  simple  exspuition.  This  mode  of 
excretion,  which  is  not  uncommon  in  haemoptysis,  it  is  difficult  to 
comprehend,  particularly  in  the  vertical  position.  Some  physi- 
cians have  supposed,  it  is  true,  that,  in  such  cases,  the  expectora- 
ted matter  is  secreted  in  the  larynx ;  but  this  supposition,  which 
is  without  confirmation,  leaves  still  unexplained  the  ascent  of 
the  blood  or  mucus.  It  seems  to  us,  on  the  contrary,  that  it 
may  be  understood  by  taking  into  account,  1,  the  form  of  the 
air  passages,  which,  being  narrow  at  their  termination,  become 
gradually  larger,  to  their  junction  with  the  trachea ;  2,  the  com- 
pression which  they  undergo  at  each  expiratory  effort ;  3,  the 
specific  lightness  of  the  mucus,  by  its  admixture  with  the  air ;  4, 
and  particularly  the  difference  in  the  duration  of  inspiration  and 
expiration  :  the  latter  being  short,  the  air  issues  from  the  air  pas- 
sages with  more  velocity  than  it  enters  them,  necessarily  commu- 
nicating to  the  matters  contained  in  the  bronchi  and  trachea  an 
ascending  movement,  which  more  than  counteracts  that  imparted 
to  them  by  inspiration. 

Thus,  sometimes,  matters,  when  poured  in  abundance  into  the 
bronchi,  are  carried  into  the  mouth  by  a  single  impulsion,  as  is  ob- 
served in  certain  cases  of  haemoptysis  and  emphysema,  in  which 
the  blood  and  pus  are  suddenly  rejected  in  great  quantity ;  they 
are  sometimes  arrested,  as  before  stated,  in  the  pharynx,  and 
afterwards  forced  by  exspuition  into  the  mouth,  whence  they  are 
rejected  from  the  body. 

The  act  by  which  the  mucus  lodged  into  the  mouth  or  exhaled 
into  this  cavity  is  rejected,  is  called  spitting  (excreation).  When 
this  is  often  repeated,  the  phenomenon  is  termed  crachottment ;  it 
occurs  particularly  in  gastric  derangement,  and  in  cases  in  which 
the  mouth  is  bitter  and  pasty,  and  in  nausea.  Spitting,  exspuition 
and  expectoration  have  this  in  common,  that  they  may  be  produced 
by  a  rapid  expiration ;  but  the  cause  which  produces  expectoration 
is  below  the  glottis,  that  which  excites  exspuition  is  above,  and 
that  of  spitting  is  in  the  mouth ;  in  the  first  case,  the  obstacle 
which  augments  the  force  of  the  expired  air  is  the  glottis,  in  the 
second,  the  isthmus  of  the  fauces,  and  in  the  third,  the  lips.* 

Expectoration,  exspuition  and  spitting  may  be  rare  or  frequent, 
easy  or  laborious,  and  sometimes  impossible.  They  are  often  ac- 
companied with  pain,  as  is  observed  in  peripneumonia,  angina  and 
inflammation  of  the  tongue. 

The  term  sputa,  is  applied  to  the  matters  which  come  from  the 
bronchi,  trachea,  larynx,  pharynx,  isthmus  of  the  fauces,  and  the 
posterior  part  of  the  nasal  fossae  or  mouth,  and  which  are  rejected 
through  the  opening  of  this  latter  cavity,  commonly  in  a  liquid 
form,  and  in  small  masses  at  once.  These  matters  are  generally 
the  result  of  a  morbid  secretion  of  the  mucous  membrane  which 
covers  these  organs,  or  of  their  glands  and  follicles ;  they  may 

*  The  words  exspuition  and  spitting  having  heen  vaguely  employed  by  authors, 
we  have  thought  it  better  to  give  them  a  precise  signification. 


156  SYMPTOMS. 

• 

also  be  formed  in  the  substance  of  these  parts  or  proceed  from 
those  more  remote,  having  forced  a  way  into  their  cavity. 

The  formation  of  sputa  is  not  incompatible  with  health.  There 
are  many  persons,  who  every  day  reject  a  certain  quantity,  either 
from  the  mouth  or  pharynx,  or  from  the  trachea  or  bronchi, 
without  being  supposed  to  suffer  from  disease. 

The  sputa  present  remarkable  differences,  according  to  the  parts 
from  which  they  proceed.  In  order  correctly  to  appreciate  their 
different  qualities  and  quantity,  the  physician  should  require  that 
there  be  a  vessel  for  the  exclusive  purpose  of  receiving  them. 

Their  qualities  can  be  but  imperfectly  determined  when  mixed 
with  urine,  or  received  upon  a  cloth  which  absorbs  their  more 
fluid  portion. 

The  sputa  formed  in  the  mouth,  are  more  often  owing  to  an 
increased  secretion  of  the  mucous  membrane,  than  to  that  of  the 
parotid,  submaxillary  and  sublingual  glands.  They  are  com- 
monly clear  and  almost  serous,  like  the  saliva  itself;  they  rarely 
acquire  much  consistence  or  opacity,  unless  in  acute  diseases  of 
the  gravest  character.  They  may  flow  from  the  mouth,  by  their 
weight  alone ;  they  may  be  drawn  out  without  the  assistance  of 
the  organ  which  contains  them ;  but  they  are  generally  expelled 
by  the  peculiar  act  to  which  the  term  spitting  or  sputation  has 
been  applied. 

The  sputa  from  the  isthmus  of  the  fauces  and  pharynx,  are 
generally  owing  to  inflammation  of  these  parts ;  they  are  clear, 
tenacious  and  ropy,  sometimes  mixed  with  small  cheese-like  lumps, 
which  proceed  from  the  follicles  of  the  tonsils,  and  in  certain  cases, 
with  pus,  formed,  either  in  the  tissue  of  these  glands,  or  in  the 
substance  of  the  velum  pendulum  palati,  or,  what  is  rare,  in  the 
parietes  of  the  pharynx,  and  are  rejected  by  exspuition. 

The  sputa  which  come  from  the  larynx  and  trachea  are  gen- 
erally small  in  size  and  quantity,  and  differ  but  slightly  from  those 
furnished  by  the  bronchial  ramifications  in  analogous  affections. 

The  study  of  the  latter  (expectorated  matters)  is  of  the  highest 
importance  in  all  respects ;  they  are  generally  the  result  of  a  mor- 
bid secretion  of  the  mucous  membrane ;  but  in  many  cases,  they 
proceed  from  other  parts,  particularly  the  parenchyma  of  the  lungs, 
and  the  pleura ;  and  sometimes  from  the  neighboring  large  arteries, 
liver,  or  the  cellular  tissue  which  unites  this  viscus  to  the  dia- 
phragm. 

The  sputa,  considered  independently  of  their  origin,  and  in 
regard  only  to  their  physical  qualities,  present  numerous  varieties, 
which  have  received  distinctive  appellations. 

They  are  called  serous,  when  clear  and  resembling  water ;  mucous -, 
when  of  a  thicker  consistence ;  and  viscid,  when  adherent  to  the 
vessel  in  which  they  are  contained :  this  viscidity  is  sometimes  so 
great  that  the  vessel  may  be  turned  upside  down,  without  their 
becoming  detached,  or  even,  in  some  cases,  their  molecules  moving 
among  themselves.  The  sputa  are  called  sanguinolent,  when 
they  consist  of  a  mixture  of  blood  and  mucus,  as  in  pneumonia  ; 


SYMPTOMS. 


157 


bloody,  when  they  contain  pure  blood,  as  in  haemoptysis.  They 
are  said  to  be  spotted  or  streaked  with  blood,  when  this  liquid 
appears  in  small  masses  or  in  streaks,  as  in  severe  bronchitis ; 
frothy,  when  mixed  with  bubbles  of  air,  giving  them  the  appear- 
ance of  froth ;  purulent,  when  they  contain  pus,  and  puriform, 
when  they  only  appear  to  contain  it. 

Their  color  also  presents  numerous  varieties ;  they  may  be 
white,  yellowish,  rusty,  greenish,  red,  brown,  black,  or  gray ;  in 
some  cases,  transparent,  in  others  opaque,  and  often,  colorless. 
They  may  also  present  different  shades  of  color  at  once.  Their 
form  is  generally  rounded  when  they  are  easily  detached  from  the 
mouth,  and  not  adherent  to  its  sides ;  they  are,  on  the  contrary, 
elongated,  stringy,  or  stellated,  when  viscid  ;  this  latter  form  is  fre- 
quently observed  in  typhoid  fever.  They  are  sometimes  firm,  dis- 
tinct, and  almost  hemispherical ;  sometimes  frothy,  flattened,  and 
run  together  so  as  to  form  an  homogeneous  mass.  They  vary  also 
in  consistence  ;  this  is,  in  some  cases,  aqueous,  in  others,  similar  to 
that  of  a  solution  of  gum  arabic,  the  white  of  an  egg,  or  even  gluey  ; 
they  are  still  thicker  in  some  cases  of  chronic  catarrh,  in  which  they 
appear  nearly  solid.  Their  odor  is  generally  slight ;  it  is  sometimes 
ammoniacal,  fetid  and  alliaceous  like  that  of  the  breath,  (p.  137.) 
Their  taste,  in  some  cases,  is  sweetish  ;  in  others,  saltish,  bitter  or 
sour ;  but  the  taste  generally  attributed  by  patients  to  the  sputa,  is 
rather  that  of  the  coat  which  covers  the  lining  membrane  of  the 
mouth,'  or  the  drinks  which  they  take.  In  some  persons,  the  sputa 
cause  a  sensation  of  cold,  or  heat  in  the  parts  over  which  they  pass ; 
but  their  temperature  is  generally  that  of  the  body.  Their  volume 
varies  in  the  same  persons ;  in  some,  however,  they  are  extremely 
small,  or  are  remarkable  for  their  large  size  ;  in  the  latter  case  they 
may  form  discs,  from  one  and  a  half  to  two  inches  in  diame- 
ter. They  vary  also  in  quantity  ;  being  small  from  some  patients 
each  day,  while  others  are  spitting  continually,  so  as  to  fill  the 
vessel  several  times  in  the  course  of  twenty-four  hours.  It  should 
also  be  remarked  that  in  the  same  individuals,  the  sputa  may  differ 
widely,  in  all  respects,  not  only  in  the  different  periods  of  the  same 
disease,  but  also  in  each  nycthemerum  ;  *  they  are  generally  more 
abundant,  consistent,  more  opaque  and  more  easily  rejected  in  the 
morning  than  at  other  periods  of  the  day.  Finally,  it  is  not  un- 
common for  the  same  individual  to  reject,  in  the  course  of  a  few 
minutes,  several  sputa,  differing  from  each  other  principally  in  re- 
gard to  their  color  and  consistence.  These  differences  are  still 
more  marked  in  patients,  who,  already  affected  with  a  chronic  dis- 
ease of  the  lungs,  are  attacked  with  acute  inflammation  of  these 
viscera :  in  such  cases,  the  sputa  resemble  those  from  two  different 
patients  who  make  use  of  the  same  spit-cup,  but  are  in  fact  the 
result  of  two  diseases  of  the  same  organ,  in  the  same  individual. 

To  these  considerations  respecting  the  various  appearances  of  the 
sputa,  we  shall  add  others  which  are  the  consequence  of  the  first, 

*  Nv*,  night;  »?««(?«,  day. 

14 


158  SYMPTOMS. 

and  which  enable  us  to  determine,  from  their  inspection,  the  organ 
from  which  they  proceed,  and  the  nature  of  the  disease  with  which 
that  organ  is  affected. 

The  manner  in  which  the  sputa  are  rejected  often  suffices  to  in- 
dicate their  origin ;  those  that  are  rejected  by  simple  sputation,  or 
which  flow  out  of  the  mouth,  by  their  own  weight,  originate  in 
this  cavity ;  those  which  have  been  forced  by  a  sort  of  snuffing, 
or  by  exspuition,  into  the  mouth,  proceed,  in  the  first  case,  from 
the  nasal  fossse,  in  the  other,  from  the  larynx  or  pharynx ;  those 
which  are  carried  into  the  mouth  by  the  pectoral  cough  (expectora- 
tion), come  from  the  trachea  or  bronchi,  into  which  they  have  been 
exhaled  or  poured,  owing  to  grave  alterations  of  the  pulmonary 
parenchyma,  pleura,  and  even  more  remote  organs.  It  is  useful, 
though  not  always  indispensable,  for  the  physician  to  know  the 
manner  in  which  the  sputa  are  rejected,  in  order  to  ascertain  their 
origin  ;  their  inspection  alone  suffices  for  the  solution  of  the  double 
problem,  under  consideration. 

The  serous  and  frothy  sputa  sometimes  originate  in  the  mouth, 
and  sometimes  in  the  bronchi.  In  the  first  case,  if  the  mouth  be 
free  from  alj  lesion,  they  indicate,  either  an  affection  of  the  stom- 
ach, or,  in  the  woman,  pregnancy.  If  the  membrane  of  the  mouth 
be  of  a  bright  red  color,  they  announce  an  approaching  apthous  or 
pseudo-membranous  eruption ;  if  they  are  owing  to  mercurial  in- 
fluence, the  swelling,  redness,  patches,  whitish  excoriations,  and 
the  specific  odor  of  the  mouth,  would  enable  us  to  distinguish  them 
from  the  first.  The  serous  and  frothy  sputa,  the  result  of  expec- 
toration, are  observed  in  pleurisy  and  incipient  bronchial  catarrh. 
In  the  former  case,,  their  quantity  is  very  small,  in  the  latter,  it  may 
be  very  considerable. 

The  mucous  sputa  generally  come  from  the  larynx,  pharynx, 
bronchi  or  nasal  fossse.  Some  patients  reject  every  morning  on 
awaking,  one  or  two  small,  rounded  and  dried  mucous  masses ; 
these  generally  come  from  the  nasal  fossae,  and  are  formed  during 
the  night  upon  the  free  border  of  the  velum  pendulum  palati, 
whence  they  are  forced  into  the  pharynx  and  rejected. 

The  mucous  sputa  which  originate  in  the  pharynx  are  generally 
viscid,  transparent,  contain  but  little  air,  and  are  rejected  by 
exspuition  and  with  an  expression  of  pain.  The  mucous  sputa 
which  come  from  the  larynx  are  generally  smaller  in  quantity,  and 
accompanied  with  some  alteration  of  the  voice.  Patients  not  un- 
frequently  cough  up  sputa,  formed  by  the  union  of  small  trans- 
parent globules  of  a  grayish  or  slate  color,  which  resemble  starch 
or  tapioca,  and  whose  origin  is  somewhat  obscure.  They  are 
thought  by  some  physicians  to  come  from  the  larynx;  the  numer- 
ous follicles  with  which  the  isthmus  of  the  fauces  is  furnished, 
would  lead  us  to  suppose  that  here  might  be  their  origin. 

The  mucous  sputa  secreted  in  the  bronchi  are  generally  of  a 
larger  size,  a  rounded  form,  which  they  preserve  in  the  vessel,  and 
a  color  varying  with  the  nature  and  period  of  the  disease.  They 
are  transparent  in  recent  catarrh  ;  transparent,  viscid  and  stellated 
in  typhoid  fever ;  and  opaque  in  chronic  catarrh. 


SYMPTOMS.  159 

Many  persons,  in  health,  every  morning  reject  several  sputa,  of 
a  grayish  or  blackish  color ;  this  color  is  owing  to  the  smoke  which 
collects  from  lamps,  candles,  &c.,  particularly  in  small  apartments. 

In  many  diseases,  the  sputa  are  purulent ;  the  product  of  the 
secretion  of  the  mucous  membrane  lining  the  air  passages,  may 
also  in  some  cases  present  the  appearance  of  pus  which  arises  from 
ulceration,  tubercular  softening,  or  the  rupture  of  an  abscess  in  the 
neighboring  parts.  The  importance  of  distinguishing  between 
purulent  sputa  and  those  simply  puriform,  has  been  long  recog- 
nized, and  attempts  have  been  made  to  find  some  sign  distinctive 
of  each.  Numerous  chemical  experiments  have  been  tried;  the 
miscroscope  has  been  employed  in  the  examination  of  mucous  and 
pus,  but  no  satisfactory  results  have  as  yet  been  obtained  ;  it  is  for 
this  reason  that  we  have  considered  the  sputa  presenting  these 
characteristics  in  connection  with  each  other. 

Pus  which  escapes  suddenly  and  in  abundance  from  the  mouth 
(vomica)  always  comes  from  the  pleural  cavity,  and  has  been 
transmitted  into  the  bronchi  by  means  of  a  perforation  of  the  pul- 
monary parenchyma,  being  generally  owing  to  tubercular  ulcera- 
tion which  has  made  an  opening,  either  at  once  or  successively 
into  the  pleura  and  a  bronchial  division.  The  signs  of  pneumo- 
thorax  soon  appear,  to  confirm  the  diagnosis  already  established 
from  the  vomiting  of  pus,  which  is  sometimes  preceded  and  an- 
nounced by  the  gurgling  mentioned  above.  When  pus  or  a 
puriform  liquid  is  rejected  from  the  mouth  in  abundance,  (eight  or 
ten  ounces  in  the  twenty-four  hours,)  but  by  successive  efforts  and 
in  small  quantities  at  a  time,  we  may  infer  that  it  either  proceeds* 
from  the  pleura,  as  in  the  preceding  case,  or  from  dilated  bronchi. 
Auscultation  and  percussion  show  to  which  of  these  two  affections 
these  sputa  shoulcTbe  referred. 

Pus  when  rejected  pure,  but  in  small  quantities,  may  be  owing 
to  one  of  the  two  preceding  diseases,  or  to  one  or  more  tubercular 
cavities.  If  the  sputa  be  very  fetid,  they  come  from  dilated 
bronchi  or  the  cavity  of  the  pleura  ;  if  they  do  not  possess  this  pe- 
culiarity, they  may  originate  in  one  of  these  two  sources,  or  a 
tubercular  cavity.  The  progress  of  the  disease  and  the  explora- 
tion of  the  chest  can  alone  enable  us  to  decide  these  various  points. 

Sputa  which  contain  only  streaks  or  dots  of  pus  commonly  mix- 
ed with  mucus,  and  which  are  rejected  by  expectoration,  may 
proceed  from  the  larynx  or  lungs.  The  sensation  which  precedes 
and  excites  their  expulsion,  the  alteration  of  the  voice,  the  small 
size  and  quantity  of  the  sputa,  generally  indicate  their  origin  to  be 
ulceration  of  the  larynx  of  a  tubercular  or  syphilitic  nature.  If 
the  expectorated  sputa  be  voluminous  and  abundant,  if  they  pre- 
sent opaque  streaks  which  are  parallel  or  zigzag  in  their  disposi- 
tion in  a  mass  differing  in  opacity,  and  swimming  in  a  clear  and 
serous  liquid  (pittiite  diffluente),  they  generally  proceed  from 
tubercular  softening ;  as  the  disease  progresses,  the  proportion  ot 
the  clear  and  serous  fluid  diminishes,  while  that  of  the  purulent 
matter  increases ;  so  that  in  the  last  period,  the  sputa  no  longer 


160  SYMPTOMS. 

contain  the  clear  fluid  and  are  free  from  stria,  presenting  the  ap- 
pearance of  homogeneous  pus,  but  not  mixing  with  water,  and 
affecting  but  slightly,  if  at  all,  its  transparency. 

There  is  a  disease  in  which  the  sputa  present  so  close  a  resem- 
blance with  those  of  phthisis,  that  a  physician  ignorant  of  this  fact, 
would  not  hesitate,  from  inspection  of  the  expectorated  matters,  to 
affirm  that  they  belonged  to  the  latter  disease.  It  is  in  the  rubeola 
of  adults,  that  this  peculiarity  is  noticed.  In  this  case,  however, 
the  fluid,  in  which  the  solid  portions  of  the  expectoration  float,  is 
slightly  turbid  or  opaque,  while  in  phthisis  it  is  always  trans- 
parent. 

Pure  blood,  when  it  issues  from  the  mouth  in  abundance,  with 
cough,  ordinarily  comes  from  the  bronchi ;  it  may,  however,  also 
come  from  the  nasal  fossas,  but  in  this  case,  if  the  head  of  the 
patient  be  inclined  forward,  the  blood  will  flow  from  the  nostrils  as 
well  as  the  mouth,  leaving  no  doubt  as  to  its  source.  The  blood 
which  comes  from  the  bronchi  in  large  quantities  may  be  the  re- 
sult of  a  simple  exhalation  which,  in  some  cases,  replaces  some 
other  suppressed  haemorrhage,  but  it  is  generally  connected  with 
the  presence,  in  the  lungs,  of  tubercles  in  their  crude  or  softening 
stage,  or  it  may  also  proceed  from  the  rupture  of  an  aneurismal 
tumor  into  the  air  passages.  In  the  latter  case,  a  sudden  and  fatal 
haemoptysis  is  sometimes  the  first  sign  of  arterial  lesion. 

Pure  blood,  when  thrown  up  in  moderate  quantities,  may  proceed 
from  the  same  sources,  not  excepting  the  latter.  We  have  seen,  in 
the  case  of  a  porter  at  the  Hospital  de  la  Charite,  who  presented  all 
the  signs  of  an  arterial  aneurism  of  the  chest,  the  occurrence  of 
moderate  haemoptysis  which  recurred  at  intervals  during  the  few 
weeks  previous  to  his  death.  On  examining  the  body  after 
death,  a  perforation  of  the  aneurismal  sac  and  trachea  at  their 
point  of  contact  was  discovered  together  with  such  a  disposition 
of  the  fibrinous  concretions  as  to  form  an  incomplete  and  movable 
partition,  which  alternately  permitted  and  prevented  the  escape  of 
arterial  blood  into  the  trachea.  In  this  case,  as  in  many  others, 
the  concretions  formed  an  imperfect  substitute  for  the  coats  of  the 
artery,  thus  retarding  the  death  of  the  patient. 

Moderate  haemoptysis  may  be  also  connected  with  an  organic 
lesion  of  the  heart.  In  all  cases,  the  careful  exploration  of  all  the 
circumstances  which  accompany  the  haemorrhage  is  indispensa- 
ble, in  order  to  determine  its  seat  and  nature. 

In  many  cases,  the  blood  is  rejected  mixed  with  other  liquids, 
as  saliva,  mucus,  and  pusv 

Blood  which  is  rejected  by  sputation  comes  from  the  mouth  ;  it 
sometimes  precedes  and  announces  the  opening  of  an  abscess  of 
the  alveoli  or  tonsils  ;  it  may  also  arise  from  suction  of  the  gums, 
a  physical  lesion  of  any  part  of  the  mouth,  and  scorbutic  swelling 
of  the  gums :  in  the  latter  case,  it  has  a  peculiar  odor,  is  clear, 
and  of  a  serous  consistence ;  it  often  fills  the  mouth  on  awaking, 
and  does  not  flow  during  the  waking  state,  except  on  pressure  of 
the  gums. 


SYMPTOMS. 


When  blood  appears  in  the  sputa  in  the  form  of  blackish  spots, 
it  generally  proceeds  from  the  nasal  fossae  ;  when  in  narrow 
streaks,  it  almost  always  depends  upon  the  efforts  of  the  patient 
in  exspuition  or  expectoration  in  cases  of  angina,  catarrhal,  pa- 
renchymatous  or  serous  inflammations  of  the  chest. 

Sputa  formed  by  an  intimate  admixture  of  blood  with  mucus, 
are  of  the  highest  importance  in  a  semeiological  point  of  view ; 
they  may  in  some  cases  reveal  the  existence  of  an  inflammation 
of  the  pulmonary  parenchyma,  when  there  is  no  pain  in  the  side, 
no  considerable  difficulty  of  breathing,  nor  any  phenomena  of 
auscultation  or  percussion  to  indicate  such  a  lesion.  Sputa  which 
are  viscid,  transparent,  mixed  with  small  air  bubbles,  and  of  a 
red,  yellow,  or  greenish  color,  clearly,  and  with  certainty,  indicate 
the  existence  of  pneumonia ;  those  which  resemble  a  thick  solu- 
tion of  gum  arabic,  ar%e  of  a  red  color,  and  with  or  without  a 
frothy  appearance  of  their  surface,  are  also  characteristic  of  pneu- 
monia, although  not  very  viscid,  and  often  deprived  of  air ;  the 
same  is  true  of  serous  sputa  of  a  reddish  or  brownish  color  (juice 
of  the  prune  or  liquorice),  which  announce  a  near  and  almost 
inevitably  fatal  termination  of  that  disease.  The  sputa  of  pneu- 
monia, however,  do  not  constantly  present  a  reddish,  yellow, 
or  green  color ;  there  are  some  persons  in  whom,  towards  the 
decline,  and  even  during  the  whole  course  of  this  disease,  the 
sputa  are  thick,  transparent,  and  presenting  so  remarkable  a  degree 
of  viscidity,  as  to  roll  about  in  the  spittoon,  leaving  it  almost  dry 
and  free  from  stain. 

In  some  cases,  and  particularly  at  an  advanced  stage  of  pul- 
monary phthisis,  the  sputa  appear  to  consist  of  a  mixture  of  blood 
and  pus ;  being  opaque  or  of  a  dull  red  color,  resembling  choco- 
late. 

The  false  membranes  which  are  sometimes  thrown  out  with  the 
sputa,  may  come  from  various  sources.  That  they  occasionally 
proceed  from  the  mouth  and  throat  is  evident  from  simple  inspec- 
tion of  these  parts.  The  absence  of  membranous  productions  in 
the  mouth  and  throat  shows  that  they  come  from  some  part  of  the 
air  passages  below  the  epiglottis ;  their  form  and  size  sometimes 
enable  us  to  determine  their  source.  An  alteration  of  the  voice 
generally  indicates,  in  such  cases,  that  they  proceed,  at  least  in 
part,  from  the  larynx. 

The  sputa  sometimes  contain  hard  and  concrete  matters,  having 
a  colculous  or  osseous  appearance,  as  portions  of  dental  tartar, 
small  calculi  formed  in  the  salivary  glands  and  canals,  sequestra 
proceeding  from  denuded  and  ossified  cartilages  of  the  larynx, 
osseous  or  stony  fragments  developed  in  the  bronchi,  tubercular  or 
melanotic  products  and  hydatids.  The  portions  of  tartar  are 
easily  recognized  by  their  peculiar  form,  and  the  depression 
they  leave  in  the  part  of  the  gum  which  they  occupied ;  salivary 
calculi  are  at  once  distinguishable  by  their  form  and  the  lesion  of 
the  organs  in  which  they  were  developed.  A  sequestrum  formed 
in  the  larynx  generally  produces,  before  its  expulsion,  severe 
14* 


162  SYMPTOMS. 

accidents,  and  particularly  violent  fits  of  coughing,  sometimes 
threatening  suffocation ;  the  flattened  form  of  these  fragments 
assist  in  their  diagnosis.  Bony  or  calculous  concretions  formed  in 
the  lungs  have  almost  always  a  branching  form  which  distin- 
guishes them  from  all  others.  Hydatids  are  easily  recognized ; 
they  may  come  from  the  lungs  or  liver ;  the  concomitant  signs 
generally  enable  us  to  determine  in  which  of  these  two  organs 
they  were  formed.  In  regard  to  the  presence  of  tubercular  mat- 
ter in  the  sputa  of  phthisical  patients,  some  physicians  consider  it 
common  and  easily  distinguishable.  We  are  not  ourselves  of  this 
opinion ;  during  the  thirty  years  in  which  we  have  daily  and 
carefully  examined  the  sputa  of  these  patients,  we  have  never 
been  able  to  distinguish  these  pretended  melanotic  and  tubercular 
fragments. 

Lastly,  the  odor  of  the  sputa  furnishes  important  signs.  In 
the  mercurial  and  scorbutic  swelling  of  the  gums,  and  in  certain 
syphilitic  ulcers  of  the  throat,  the  excretion  exhales  the  same  odor 
as  the  mouth  :  a  f&cal  odor  of  the  sputa  generally  indicates  the 
presence  of  pus  which  proceeds  from  the  mouth  and  isthmus  of  the 
fauces.  The  alliaceous  odor  is  peculiar  to  pus  formed  in  the 
pleura,  and  rejected  through  a  perforation  in  the  pulmonary  pa- 
renchyma. In  gangrene  of  the  lungs  the  odor  is  not  less  character- 
istic. A  urinous  fetor  of  the  sputa  should  lead  us  to  suspect  a 
lesion  of  the  pleura  analogous  to  that  described  by  Dahaen,  (a 
renal  abscess  opening  into  the  bronchi,  through  the  diaphragm 
and  ulcerated  pleura  and  lung  of  the  left  side.) 


SECTION  THIRD. 

Symptoms  furnished  by  the  Circulation. 

The  circulation  which  consists  in  the  progressive  movement  of 
the  fluids  continually  carried  from  all  parts  of  the  body  towards  the 
heart  by  means  of  the  veins  and  lymphatic  vessels,  and  those 
carried  from  the  heart  towards  the  capillary  system  by  means  of 
the  arteries,  is  performed,  in  health,  without  derangement,  and  in 
harmony  with  the  organs  which  concur  in  its  production.  Under 
the  influence  of  disease,  this  function  presents  numerous  derange- 
ments ;  some  evidently  affecting  the  entire  circulation,  or  at  least 
that  of  the  blood  ;  others  being  alone  appreciable  in  certain  organs, 
as  the  heart,  arteries,  or  veins. 

The  course  of  the  blood  may  be  accelerated  through  all  its 
canals,  as  is  observable  in  most  acute  diseases,  in  which  the  pul- 
sations of  the  heart  cannot  increase  in  strength  and  frequency, 
in  a  given  time,  without  compelling  the  veins  to  furnish,  and  the 
arteries  to  receive,  a  corresponding  supply  of  blood.  A  general 
sluggishness  in  the  movement  of  the  blood  is  equally  appreciable 
under  opposite  circumstances. 

The  force  of  the  circulation  may  be  increased  or  diminished  in 


SYMPTOMS.  163 

all  parts  of  the  circulatory  system.  We  daily  see  persons  in  whom, 
while  the  pulsations  of  the  heart  and  arteries  are  stronger  than  in 
health,  the  veins  are  harder  and  more  voluminous,  and  the  capil- 
lary system  more  injected,  as  is  apparent  in  the  increased  color 
and  marked  tumefaction  of  the  integuments;  these  phenomena 
are  particularly  remarkable  in  the  affection  known  as  inflamma- 
tory fever.  In  other  diseases,  on  the  contrary,  and  particularly 
chronic  affections  without  febrile  reaction,  the  impulse  of  the  heart 
is  almost  imperceptible,  the  pulse  soft,  the  veins  flabby  or  hardly 
apparent,  the  skin  pale  or  unequally  colored  and  often  covered  with 
livid  or  blueish  patches  which  indicate  the  languor  of  the  capillary 
circulation.  Lastly,  in  some  cases,  the  course  of  the  blood  may 
be  momentarily  suspended  in  all  parts  of  the  circulatory  system, 
as  in  syncope,  in  which  the  pulsations  of  the  heart  and  arteries 
cease,  and  the  blood  no  longer  flows  from  orifices  made  in  the 
veins.* 

Notwithstanding  the  necessary  and  reciprocal  dependence  of 
the  different  parts  of  the  circulatory  system  upon  each  other,  we 
are  led  from  many  facts  to  admit  that  each  of  them,  as  Laennec 
has  observed,  has  also  a  peculiar  existence,  which  is  more  appar- 
ent in  the  pathological,  than  in  the  healthy,  condition.  It  appears 
certain,  for  example,  that  the  capillary  circulation  is  not  entirely 
dependent  upon  the  arterial  and  venous  circulation ;  partial  con- 
gestions of  blood  in  the  capillaries  of  certain  organs,  haemorrhages 
which  occur  in  any  part  without  apparent  disturbance  of  the  rest 
of  the  circulatory  system,  stasis  of  the  blood  in  the  capillaries  of 
inflamed  parts,  all  tend  to  confirm  this  opinion.  The  independence 
of  the  arterial  system  has  not  been  as  generally  admitted;  it  hav- 
ing been  shown,  however,  by  auscultation,  in  certain  cases,  that 
the  arterial  pulsations  were  remarkably  strong,  while  those  of  the 
heart  were  extremely  feeble,  Laennec  was  led  to  conclude  with 
some  other  physiologists,  that  the  arteries  also  have  a  special 
action,  a  contractility  peculiar  to  themselves.  The  action  which 
the  veins  exert  in  counteracting  the  influence  of  gravity  and 
temperature,  would  show  that  the  course  of  the  blood  in  these, 
is  not  entirely  subordinate  to  the  general  circulation. 

We  shall  now  proceed  to  examine  successively  the  symptoms 
furnished  by  each  of  the  organs  of  circulation,  the  heart,  arte- 
ries, capillary  system,  veins,  and  the  lymphatic  vessels  and 
glands. 

$  I.  Circulation  of  the  Blood.  —  A.  The  pulsations  of  the  heart 
may  become  variously  deranged. 

Many  of  the  symptoms  of  which  it  is  the  seat,  have  claimed 
the  attention  of  physicians  of  all  ages,  particularly  in  the  diseases 
which  affect  this  organ  itself.  The  force  and  feebleness  of  its  pul- 
sations, their  regularity,  the  place  and  extent  in  which  they  are 

*  Many  persons  have  been  able  to  suspend  for  a  certain  time,  by  an  effort  of 
will,  the  motions  of  the  heart  and  the  arterial  pulsations  ;  some  have  died  in 
attempting  to  repeat  this  dangerous  experiment. 


164  SYMPTOMS. 

felt,  have  been  carefully  investigated  by  observers,  and  added  as 
signs  of  more  or  less  importance  to  the  history  of  these  different 
lesions.  Many  practitioners  have  for  a  long  time  been  in  the  habit 
of  examining  this  organ  by  the  immediate  application  of  the  ear 
over  the  region  which  it  occupies ;  but  it  is  to  the  work  of 
Laenriec  that  we  are  indebted  for  the  accurate  knowledge  and 
appreciation  of  this,  as  also  many  other  pathological  phenomena. 

The  pulsations  of  the  heart  should  be  examined  with  reference 
to  the  four  following  points,  viz:  the  extent  and  place  in  which 
they  are  audible,  the  stroke  or  the  force  of  the  impulse  of  the 
organ,  the  nature  and  intensity  of  the  sound,  and  finally,  the 
rhythm  according  to  which  these  different  parts  contract. 

1.  In  a  healthy  man,  and  in  the  adult  age,  the  pulsations  of  the 
heart  are  only  audible  in  the  space  comprised  between  the  cartila- 
ges of  the  fifth  and  seven  true  ribs,  and  in  the  corresponding 
points  of  the  sternum.  The  pulsations  of  the  left  cavities  are 
principally  felt  in  the  first,  and  those  of  the  right  in  the  second 
point.  This  space  in  which  the  motions  of  the  heart  are  percep- 
tible is  much  more  limited  in  very  fat  subjects,  and  those  who 
have  been  subjected  to  repose  and  diet ;  it  is  greater  in  lean  indi- 
viduals, whose  chests  are  narrow,  in  children  after  exercise  or 
meals,  or  under  the  influence  of  a  lively  emotion.  In  these  cases, 
the  pulsations  may  be  perceptible  over  the  greater  part,  or  even 
the  whole  of  the  left  side.  When  under  the  influence  of  disease, 
the  pulsations  of  the  heart  are  audible  over  a  greater  extent  than 
in  health ;  they  become  progressively  perceptible,  1,  in  the  left 
side  of  the  chest,  from  the  arm-pit  to  the  region  of  the  stomach ; 
2,  in  the  same  region  of  the  right  side ;  3,  in  the  posterior 
part  of  the  left  chest;  4,  in  the  posterior  right  chest.  When 
perceptible  over  a  greater  extent  in  disease,  they  depend  upon 
a  lesion  of  the  heart  itself,  and,  according  to  some  authors, 
to  lesions  of  the  neighboring  parts.  Laennec  thought  that  in- 
duration of  the  pulmonary  tissue,  effusion  of  serum  into  the 
pleura,  and  the  presence  of  tubercular  cavities,  might  occasion 
this  phenomenon ;  but  generally,  in  these  cases,  the  difference  is 
not  well  marked  and  often  doubtful :  it  is  particularly  in  the 
heart  itself  that  are  found  the  causes  which  increase  the  extent, 
over  which  its  pulsations  are  felt.  It  was  the  opinion  of  Laennec 
that  this  extent  was  in  direct  ratio  with  the  feebleness  and  thin- 
ness of  the  parietes  of  the  heart ;  that  the  size  of  the  heart  does 
not  affect  the  extent  over  which  the  pulsations  are  perceptible, 
unless  accompanied  with  enlargement  of  its  cavities.  The  trans- 
mission of  the  sounds  of  the  heart  appear  to  us  also  to  depend 
upon  certain  conditions  presented  by  the  chest,  and  which  render 
it  more  fitted  to  conduct  the  sounds  produced  within  its  cavity. 
There  are  some  individuals  in  whom,  when  in  a  state  of  complete 
physical  and  moral  quiet,  the  pulsations  of  the  heart  are  trans- 
mitted to  almost  all  parts  of  the  chest,  although  presenting  in  the 
precordial  region  no  more  than  their  ordinary  force,  and  unaccom- 
panied by  any  signs  of  disease,  either  of  the  heart  or  other  tho- 
racic organs. 


SYMPTOMS.  165 

The  space,  in  which  the  pulsations  of  the  heart  are  audible,  may 
become  diminished ;  this  is  observed  in  rare  cases  of  atrophy  of 
this  organ. 

The  cardiac  pulsations  may  be  perceptible  in  a  place  differing 
from  that  where  they  ordinarily  appear.  This  phenomenon  may 
be  owing  to  a  general  transposition  of  the  viscera  ;  such  cases  are 
congenital,  and  present  nothing  morbid.  But  generally,  when  the 
pulsations  are  perceptible  above  or  below,  to  the  right  or  left  of  the 
place  where  they  are  ordinarily  felt,  the  phenomenon  is  owing  to 
some  pathological  condition.  The  presence  of  a  tumor  or  the  ac- 
cumulation of  fluid  in  one  side  of  the  chest,  in  the  mediastinum  or 
abdomen,  are  the  more  common  causes  of  this  displacement.  In 
some  cases,  the  pulsations  differ  in  their  place  of  appearance  at 
different  times ;  this  phenomenon  which  authors  have  considered 
as  peculiar  to  hydropericardium,  is  very  rare,  and  difficult  to 
detect. 

2.  The  beating  or  impulse  is  a  sensation  of  percussion  conveyed 
to  the  ear,  or  hand  of  the  observer,  by  the  cardiac  pulsations. 

When  the  conformation  of  the  heart  is  in  perfect  harmony  with 
that  of  other  parts,  this  impulse  is  almost  imperceptible ;  often 
entirely  so ;  it  increases  under  the  influence  of  the  causes  which 
hasten  the  pulsations  of  this  viscus,  and  becomes  again  natural 
when  these  cease  to  act. 

In  hypertrophy  of  the  heart  this  impulse  generally  becomes 
stronger  as  the  thickness  of  the  parietes  of  this  viscus  is  increased  ; 
and  is  sometimes  carried  to  such  a  degree  as  to  heave  the  head  of 
the  observer ;  the  greater  the  hypertrophy,  the  more  slowly  this 
heaving  takes  place.  There  are,  however,  numerous  exceptions  to 
this ;  for  it  is  not  uncommon  to  meet  with  patients  in  whom  the 
heart  has  acquired  an  enormous  size,  from  thickening  of  its  walls 
and  dilatation  of  its  cavities,  without  any  corresponding  increase 
in  the  force  of  the  impulse ;  it  is  even  sometimes  feebler  than  in 
the  normal  condition. 

The  impulse  is  produced  at  the  moment  of  vent^c,ular  contrac- 
tion. Hypertrophy  of  the  auricles  may,  however,  also  give  to  the 
ear  or  hand  a  very  perceptible  impulse ;  but  this  is  deeper  and 
more  feeble  than  that  which  depends  upon  ventricular  contraction. 
In  health,  there  is  never  but  one  impulse  to  each  systole  of  the 
heart ;  in  some  diseases  of  this  viscus,  succeeding  the  first  impulse 
which  corresponds  to  the  contraction  of  the  ventricles,  two  others, 
isochronous  with  their  dilatation,  have  been  observed.  M.  M. 
Andral  *  and  Bouillaudf  each  cite  a  case  of  this  kind.  We  have 
also  had  occasion  in  several  instances  to  observe  this  phenomenon, 
without  being  able  to  find  by  comparison  of  the  symptoms  and 
anatomical  lesions,  a  satisfactory  explanation  of  this  triple  impulse. 

The  impulse  is  ordinarily  confined  to  the  precordial  region ;  it 
sometimes  extends  to  the  neighboring  portion  of  the  sternum  and 

*  Notes  a  la  quatritjme  edition  de  Laennec,  t.  Hi.  p.  26. 
f  Traitd  climque  des  Maladies  du  C&ur,  t.  1,  p.  148. 


166  SYMPTOMS. 

epigastrium,  rarely  beyond,  unless  the  heart  be  both  thickened  and 
dilated. 

The  absence  of  impulse,  like  that  of  sound,  in  the  precordial 
region  depends,  either  upon  a  natural  feebleness  in  the  contractions 
of  the  heart,  or  rather  upon  the  position  of  this  viscus,  it  being  situat- 
ed deep  in  the  mediastinum,  and  entirely  covered  by  the  lungs,  an 
anatomical  disposition  not  urifrequently  occurring,  and  which  is 
sometimes  produced  by  pulmonary  emphysema.  The  impulse  of 
the  heart  is  also  wanting  in  cases  of  considerable  effusion  of  liquid 
into  the  cavity  of  the  pericardium. 

3.  Nature  and  intensity  of  the  sound.  If  the  ear  or  stethoscope 
be  applied  to  the  region  of  the  heart  in  a  healthy  person,  two  suc- 
cessive, and  different,  sounds  are  heard ;  the  first,  is  dull  and  pro- 
longed, coincides  with  the  vertricular  systole  and  is  isochronous 
with  the  pulse.  Succeeding  this,  is  another,  which  is  clearer  and 
smarter,  being  analogous  to  the  sound  produced  by  the  flapping  of 
a  bellows'  valve,  and  occurring  during  the  diastole  of  the  ventri- 
cles. Many  theories  have  of  late  years  been  proposed  by  physi- 
cians and  physiologists,  in  order  to  explain  the  mechanism  and 
cause  of  these  two  sounds.  They  have,  by  some,  been  referred  to 
the  contraction  of  the  auricles  and  ventricles,  by  others,  to  the  im- 
pulse of  the  blood  against  the  parietes  of  the  heart  and  great  vessels  ; 
others  have  attributed  them  to  the  collision  of  the  particles  of  this 
fluid  with  each  other,  and  again  others  to  the  successive  impulse 
of  the  point  and  base  of  the  heart  against  the  anterior  parietes 
of  the  chest ;  but  the  theory  of  Roannet,  which  refers  the  sounds 
of  the  heart  to  the  action  of  the  valves  is  that  which  at  present  is 
most  generally  admitted.  According  to  this  physician,  the  first 
sound  is  produced  by  the  closure  of  the  mitral  and  tricuspid 
valves  ;  the  second,  by  the  sudden  closure  of  the  sigmoid  valves  of 
the  aorta  and  pulmonary  artery.  This  theory  is  favored  by  the 
greater  number  of  pathological  facts ;  there  are  however  many 
abnormal  sounds  of  the  heart,  which  cannot  be  explained  by  this, 
or  any  other  ,y*t  proposed.* 

In  health,  the  two  sounds  of  the  heart  have  each  a  peculiar 
character,  which,  in  disease,  may  become  variously  modified.  At 
one  time,  the  sounds  become  duller  or  more  clear;  at  another, 
they  are  replaced  by  others  which  have  received  various  names. 
It  is  exceedingly  rare  for  the  both  sounds  to  be  altered  at  the  same 

*  From  the  highly  interesting  and  conclusive  experiments  of  Drs.  Pennock  and 
Moore,  of  Philadelphia,  and  the  committees  of  the  British  Association,  it  would 
appear  that  the  first  sound  of  the  heart  is  probably  caused  by  a  combination  of  that 
caused  by  the  contraction  of  the  auricles,  the  flapping  of  the  auriculo-ventricular 
valves,  the  rush  of  blood  from  the  ventricles,  and  the  sound  of  muscular  contrac- 
tion. But  it  is  to  the  latter  that  it  appeared  mainly  attributable,  its  dull  sound  and 
prolonged  duration  being  owing  to  the  progressive  character  of  the  full  systolic 
effort  from  fundus  to  apex. 

The  second  sound,  according  to  these  experiments,  is  caused  exclusively  by  the 
closure  of  the  semilunar  valves,  from  the  reaction  of  the  arterial  columns  of  blood 
upon  them.  The  cause  of  the  second  sound  corresponds  nearly  with  Roannet's 
theory.— TRANS. 


SYMPTOMS.  167 

time ;  in  most  cases,  one  alone  presents  modifications  in  its  tone, 
nature  or  duration. 

The  sounds  of  the  heart  are  dull  and  stifled,  in  cases  of  consid- 
erable hypertrophy,  thickening  of  its  valves,  or  when  the  free  play 
of  the  latter  has  been  obstructed  by  the  formation  of  concretions 
upon  their  surface.  In  those  cases,  they  are  sometimes  dry  and 
hard,  a  modification  to  which  M.  Bouillaud  has  applied  the  term 
bruit  de  parchemin  *  or  parchment  sound. 

Increased  clearness  of  the  sounds  is  a  very  rare  phenomenon ;  it 
is  however  observed  in  dilatation  with  attenuation  of  the  parietes 
of  the  heart. 

It  frequently  happens  that  the  sounds  of  the  heart  are  replaced 
or  masked  by  a  bellows  murmur,  so  called  from  its  exact  resem- 
blance to  the  sound  of  that  instrument.  This  murmur  is  loud  or 
feeble,  sometimes  just  perceptible,  and  sometimes  confined  to  a 
limited  space,  or  extending  over  the  whole  precordial  region  ;  in  the 
latter  case,  there  is  generally  some  point  in  which  it  presents  its 
maximum  intensity,  a  circumstance  which  may  be  of  importance 
in  the  diagnosis  of  the  disease.  In  some  very  rare  cases,  both  the 
normal  sounds  of  the  heart  are  masked  or  replaced  by  this  mur- 
mur, which  may  lead  us  to  supect,  either  the  simultaneous  altera- 
tion of  both  orifices,  the  arterial  and  auriculo  ventricular,  or  a 
twofold  alteration  in  one  of  those  orifices,  causing  its  contraction, 
and  inefficiency  of  its  valves. 

The  bellows  sound  whatever  be  its  degree  of  intensity,  is  not 
pathognomonic  of  any  particular  disease  of  the  heart,  for  while,  on 
the  one  hand,  it  may  exist  in  nearly  all  the  affections  of  this  viscus, 
on  the  other,  it  fails  in  some  of  the  most  severe,  and  particularly 
in  contractions  of  its  orifices.  The  bellows  sound  may  exist  in 
simple  pericarditis,  hypertrophy,  and  particularly  that  form  called 
concentric  hypertrophy.  But  it  is  most  often  found  in  fibrous,  car- 
tilaginous or  cretaceous  contractions  of  the  orifices,  and  inefficiency 
of  the  valves.  It  also  frequently  exists  in  cases  in  which  the  ac- 
tion is  increased  without  any  material  lesion  of  its  tissue,  as  in 
nervous  palpitations.  Finally,  it  may  be  heard  in  plethoric  indi- 
viduals, pregnant  women,f  but  particularly  in  anemic  persons,  in 
young  girls  affected  with  chlorosis,  and  after  abundant  haemor- 
rhages, as  has  been  shown  by  the  observations  and  experiments  of 
Dr.  Marshall  Hall,  of  London.^ 

It  follows  from  these  facts,  that  the  bellows  murmur  may  be  de- 
veloped in  various  and  even  opposite  conditions :  how  uncertain 
then  are  all  those  explanations  in  which  this  sound  is  attributed  to 
a  single  mechanism. 

Many  other  sounds  have  been  revealed  by  auscultation,  which 
Laennec  has  justly  considered  but  varieties  of  the  bellows  sound, 
and  which  have  been  designated  by  the  terms,  filing  (bruit  de 
lime),  rasping  (bruit  de  rape),  sawing-  (bruit  de  scie),  and  musical 

*  Trait&  des  Maladies  du  Coeur,  t.  1,  p.  162. 

t  Vide  a  good  thesis  by  M.  Jucquemier     Paris,  1837,  No.  366. 

J  Med.  chirurg.  trans,  t.  xvii. 


168  SYMPTOMS. 

or  whistling  sounds.  The  rasping  or  filing  sound  gives  to  the  ear 
a  sensation  of  harshness  or  roughness,  which  has  been  compared 
to  the  sound  produced  by  filing  wood.  If,  in  these  cases,  the  hand 
be  applied  to  the  precordial  region,  a  peculiar  vibration  is  felt 
called  the  purring  tremor  (premissement  cataire),  first  pointed  out 
by  Corvisart,  and  which  Laennec  compared  to  the  purring  of  cats. 
The  sawing  sound  closely  resembles  the  sound  of  the  saw,  when 
heard  at  a  little  distance.  It  has  also  been  compared  by  M.  Bouil- 
laud  to  the  sound  of  the  letter  S,  when  prolonged.  The  whistling 
or  musical  sound  which  Laennec  never  distinguished  except  in  the 
arteries,  we  have  several  times  observed  in  the  heart  itself;  in  one 
case  it  was  so  intense  as  to  be  heard  at  the  distance  of  several  feet. 

The  rasping,  filing  and  sawing  sounds  and  the  purring  tremor 
are  most  commonly  heard  in  contraction  of  the  orifices,  particularly 
if  the  valves  present  cretaceous,  rough  or  unequal  indurations. 
We  have,  however,  several  times  observed  the  rasping  sound  in 
cases  of  anemia,  and  after  abundant  bleeding.  The  same  phe- 
nomenon has  been  noticed  under  similar  circumstances  of  Dr. 
Marshall  Hall. 

The  musical  or  whistling  murmur  of  the  heart  has  not  been  con- 
nected with  any  distinct  lesion  of  this  viscus ;  in  the  two  cases 
which  had  presented  this  phenomenon  and  in  which  an  autopsy 
was  made,  the  existence  of  hypertrophy  with  dilatation  of  the 
left  cavities  was  discovered,  without  lesion  of  the  orifices. 

We  shall  close  the  history  of  the  anormal  sounds  of  the  heart, 
by  briefly  noticing  the  bruit  argentin,*  or  silvery  sound,  pointed 
out  by  Laennec,  and  the  semeiological  value  of  which  is  not  yet 
determined.  It  may  be  imitated,  says  M.  Filhos,  by  placing  the 
pulp  of  the  middle  finger  just  within  the  meatus  externus,  so  as 
completely  to  close  it,  and  at  the  same  time  tapping  it  lightly  with 
the  other  hand.f  Most  authors  have  considered  this  sound  as 
peculiar  to  hypertrophy,  occurring  when  the  contractions  of  the 
heart  have  become  very  powerful.  Laennec  supposed  it  to  be 
exclusively  owing  to  the  presence  of  air  bubbles  within  the 
pericardium,  together  with  hypertrophy  of  the  heart ;  but  this 
opinion  has  not  yet  been  verified  by  autopsies.  M.  Bouillaud 
attributed  the  same  phenomenon  to  the  stroke  of  the  heart  against 
the  thoracic  parietes.  He  thought  that  the  silvery  sound  which  is 
always  produced  during  the  ventricular  systole,  was  only  a  sound 
superadded,  and  which  does  not  render  the  two  normal  sounds 
inaudible. 

If,  in  the  healthy  condition,  the  gliding  of  the  heart  within  the 
pericardium  be  unaccompanied  by  any  appreciable  sound,  this  is 
no  longer  the  case  after  the  formation  of  false  membranes  upon 
the  serous  envelope  of  the  heart,  which  destroy  its  smoothness, 
and  which  are  the  result  of  inflammation.  Thus  abnormal  sounds 
may  be  produced  in  the  pericardium,  as  in  the  pleura,  and  under 

*  This  is  the  metallic  tinkling  of  Bouillaud,  or  the  auricula-metallic  sound  of 
M.  Filhos. 

f  Theses  de  Paris,  1833,  No.  132,  p.  14. 


SYMPTOMS.  169 

the  same  conditions.  These  sounds  were  observed  by  Laennec, 
but  he  did  not  attach  to  them  due  importance.  He  speaks  of  a 
sound  of  leather,  which  he  at  first  thought  depended  upon  pericar- 
ditis, but  which  he  afterwards  confounded  with  the  metallic  tink- 
ling, attributing  it  to  the  presence  of  air  bubbles  in  the  pericar- 
dium.* M.  Collin  was  the  first  to  give  a  correct  description  of 
this  phenomenon,  and  point  out  its  semeiological  value  by  con- 
necting it  with  the  existence  of  false  membranes,  and  thus  con- 
stituting it  one  of  the  pathognomonic  signs  of  pericarditis.  This 
sound  presents  various  degrees  of  intensity ;  to  the  feeblest  of 
these,  M.  Bouillaud  proposed  to  apply  the  term  grazing  (frole- 
ment)  ;  he  compared  this  sound  to  that  produced  by  the  rumpling 
of  taffeta,  parchment,  or  a  bank  note  between  the  fingers ;  this 
sound  which  is  very  superficial,  is  heard  during  the  systole  and 
diastole,  but  is  more  marked  during  the  former.f  The  sound  of 
new  leather  (cuir-neuf),  investigated  by  M.  Collin,  resembles 
that  produced  by  a  horseman  on  a  new  saddle.  This  sound  is 
observed  under  the  same  circumstances  as  the  preceding ;  but  it 
seems  to  depend  on  false  membranes,  which  are  harder  and  more 
resistant.  Lastly,  when  the  false  membranes  have  become  fibro- 
cartilaginous,  a  much  ruder  sound  is  produced,  for  which  M.  Bouil- 
laud has  proposed  the  term  scraping  sound  (bruit  de  raclemenf).^ 
These  different  sounds  are  often  important  in  the  diagnosis  of  peri- 
carditis. 

4.  The  term  rhythm,  Laennec  applied  to  the  order  of  succession 
in  the  contractions  of  the  different  parts  of  the  heart,  and  to 
their  respective  and  relative  duration.  In  health,  the  first  or  dull 
sound  which  coincides  with  the  ventricular  systole  is  nearly  iso- 
chronous with  the  pulsation  of  the  radial  artery.  Succeeding 
this,  is  the  second  or  flapping  sound,  between  which  and  the  first, 
according  to  M.  Marc  d'Espine,  there  is  a  very  short  interval  of 
silence,  during  which,  with  great  attention,  the  arterial  pulsation 
can  be  distinguished.  To  this  succeeds  a  brief,  but  well  marked, 
period  of  repose,  after  which  the  ventricles  again  contract  with 
the  dull  sound  and  the  gradual  progression  peculiar  to  them.  The 
contraction  of  the  ventricles,  the  flapping  sound  and  the  pause 
which  succeeds,  are  not  of  equal  duration.  The  duration  of  the 
first  sound  is  almost  double  that  of  the  second,  the  latter  being 
about  equal  to  the  interval  of  repose,  and  sometimes  a  little  less. 

This  succession  in  the  motions  and  sounds  of  the  heart  is  best 
distinguished  when  the  pulsations  of  this  organ  are  fewest  in  a 
given  time ;  indeed,  when  the  number  of  the  arterial  pulsations 
becomes  much  increased,  the  ear  can  no  longer  clearly  distinguish 
the  period  of  silence  to  which  we  have  just  alluded. 

In  disease,  the  duration  of  each  sound  may  become  modified ; 
thus,  in  some  cases  of  hypertrophy,  the  first  sound  is  so  prolonged 
as  sometimes  to  mask  the  flapping  sound,  at  the  same  time  short- 

*  T.  3,  p.  5,  4th  edition. 

f  Trait6  Clinique  des  Maladies  du  Cceur,  t.  1,  p   457. 
j  L.  c.  p.  198. 
15 


170  SYMPTOMS. 

ening  the  period  of  silence,  and  rendering  it  almost  imperceptible. 
A  loud  and  continuous  bellows  murmur  is  also  not  unfrequently 
heard  in  the  precordial  region,  which  replaces  or  entirely  masks  both 
the  normal  sounds,  together  with  the  interval  of  silence.  We  have 
previously  referred  to  those  cases  in  which  the  rhythm  of  the  car- 
diac pulsations  is  so  perverted,  that  following  a  single  ventricu- 
lar systole,  two,  three,  or  four  other  impulses  coincident  with  the 
diastole  are  distinguished.  Finally,  the  natural  rhythm  of  the 
heart  may  be  perverted  by  intermittences,  irregularities,  or  ine- 
qualities in  its  pulsation  :  the  latter  may  be  accelerated  or  retarded, 
all  which  phenomena  will  be  considered  in  connection  with  the 
pulse. 

The  symptoms  furnished  by  auscultation  of  the  heart  should 
never  be  separated  from  those  which  are  the  results  of  percussion. 
In  the  healthy  condition,  percussion  over  the  precordial  region  gives 
an  obscure  sound  over  an  extent  not  exceeding  two  inches  square. 
This  space  increases,  and  its  sound  becomes  duller,  owing  to 
increased  size  of  the  heart,  or  a  liquid  effusion  into  the  pericardium. 
In  a  treatise  published  in  1826,  M.  Louis  proclaimed  the  impor- 
tance of  the  signs  furnished  by  percussion  of  the  precordial  region 
in  the  diagnosis  of  pericarditis ;  he  proved  that  the  more  or  less 
rapid  increase  in  the  extent  over  which  a  dull  sound  is  obtained, 
is  the  most  certain  sign  of  liquid  effusion  and,  consequently,  peri- 
carditis ;  for  an  effusion  confined  to  the  pericardium  is  an  almost 
constant  sign  of  inflammation  ;  hydropericardium  without  inflam- 
mation rarely  occurs  except  in  cases  of  general  dropsy. 

B.  The  term  pulse  (pulsus)  is  applied  to  the  beating  of  the 
arteries  produced  by  the  afflux  of  blood  propelled  by  the  heart  at 
each  contraction. 

Galen  was  the  first  to  call  the  attention  of  physicians  to  this 
phenomenon.  Those  who  preceded  him  have  hardly  alluded  to 
it,  and  seem  to  have  overlooked  it. 

The  pulse,  in  health,  is  equal,  regular,  supple,  and  moderate  in 
strength.  The  number  of  the  pulsations  varies  with  the  age, 
temperament,  sex,  stature,  idiosyncrasy  and  other  accidental  cir- 
cumstances. It  has  been  for  a  long  time  supposed  that  the  num- 
ber of  arterial  pulsations,  during  the  first  months  of  life,  were 
about  one  hundred  and  forty  per  minute  ;  at  the  second  year,  one 
hundred ;  at  puberty,  eighty ;  from  sixty-five  to  seventy-five  in 
adults,  and  from  fifty  to  sixty  in  old  age.  But  it  would  appear 
from  works  recently  published  that  this  estimation  of  the  fre- 
quency of  the  pulse,  in  the  different  periods  of  life,  is  incorrect. 
Billard  asserts  that  the  frequency  of  the  pulse  in  the  new  bom 
infant  is  often  no  greater  than  in  the  adult,  and  in  forty  infants 
from  one  to  ten  days'  old,  he  found  eighteen  in  whom  the  pulse 
was  less  than  eighty  in  the  minute.*  Dr.  Valleix  indicates  the 
number  eighty-seven,  as  the  medium  of  the  frequency  of  the 

*  Mai.  des  Enf ,  p.  67. 


SYMPTOMS.  1 71 

pulse  in  infants  aged  from  two  to  twenty-one  days.*  Finally, 
M.  M.  Leuret  and  Mitivie,  by  studying  the  comparative  frequency 
of  the  pulse  in  a  great  number  of  persons,  both  old  and  young, 
have  shown  it  to  be  greater  in  the  former  than  in  the  latter,  since 
the  mean,  in  the  aged,  was  seventy-three,  and,  in  the  youth, 
sixty-five,  f  It  would  be  desirable  that  the  researches  upon  the 
frequency  of  the  pulse  during  the  first  periods  of  life,  be  made 
upon  other  than  hospital  patients,  as  these  are  badly  nourished, 
and  not  in  the  ordinary  healthy  conditions.  It  is  also  necessary 
that  the  results  should  be  deduced  from  a  great  number  of  facts. 
The  frequency  is  a  little  greater  in  women,  in  individuals  of  a 
sanguine  or  nervous  temperament,  and,  it  is  said,  in  those  of  small 
stature.  It  has  been  shown,  by  repeated  observations,  that  the 
proportion  of  adult  subjects  in  whom  the  number  of  arterial  pul- 
sations is  below  sixty,  and  even  fifty  per  minute,  is  greater  than 
is  generally  supposed.  There  are  many  persons  in  whom  the 
pulse  is  not  over  thirty-six  or  forty,  in  others,  it  has  been  observed 
as  high  as  one  hundred  per  minute.  Whitt  saw  a  woman  whose 
pulse,  in  health,  beat  one  hundred  and  twenty  per  minute. 

Beside  these  individual  varieties,  the  number  of  pulsations  be- 
comes increased  after  a  meal,  by  exercise,  emotions,  and  during 
pregnancy;  it  is  diminished  in  the  sitting  or  horizontal  posture, J 
by  repose,  diet,  loss  of  blood,  and  particularly  the  use  of  digitalis ; 
it  is  not  rare  however  for  the  pulse  to  become  accelerated  after 
abundant  haemorrhages,  and  all  excessive  evacuations.  In  some 
persons,  the  frequency  of  the  pulse  during  convalescence  is  less 
than  in  health.  It  has  been  said  that  the  pulse  presents,  at  dif- 
ferent hours  of  the  day  and  night,  slight  modifications,  which, 
according  to  the  assertions  of  Brian  Robinson,  coincide  with  those 
of  the  barometer  and  thermometer.  But  these  observations,  sup- 
posing them  to  be  correct,  are  unimportant,  as  offering  no  useful 
application.  The  pulse  also  presents  varieties  in  different  individ- 
uals, in  regard  to  the  force,  regularity  and  equality  of  its  pulsa- 
tions ;  it  is  highly  important  for  the  physician  to  be  acquainted 
with  the  normal  condition  of  the  circulation  of  persons  to  whom 
he  is  called  in  sickness  ;  this  knowledge  is  always  useful,  and  often 
indispensable  in  order  to  appreciate  the  changes  effected  in  the  va- 
rious circulatory  phenomena,  and  particularly  the  pulse,  through 
the  influence  of  disease. 

I  have  seen  a  lady  whose  pulse,  during  the  paroxysms  of  inter- 
mittent fever,  did  not  beat  above  sixty  per  minute,  to  the  great 
astonishment  of  her  physician.  This  astonishment  would  have 
ceased  had  he  counted  the  number  of  pulsations  during  the  inter- 
mission, these  being  not  above  forty  per  minute. 

There  are  many  precepts  which  should  not  be  neglected  in  the 
mode  of  feeling  the  pulse. 

*  CZm.,  des  Mai.  des  Enf.,  p.  18. 

f  De  la  Frequence  du  pouls. 

I  Guy's  Hospital  Reports,  April,  1836. 


172  SYMPTOMS. 

The  physician  should  wait  till  the  patient  shall  have  recovered 
from  the  emotion  produced  by  his  presence,  requesting  him  to  pre- 
serve absolute  silence  and  to  remain  in  the  sitting  or  horizontal 
posture.  The  pulse  may  be  examined  at  the  temples,  lateral  parts 
of  the  neck,  arm,  thigh,  wrist,  and  wherever  the  arteries  are  suffi- 
ciently large  and  superficial ;  but  the  radial  artery  is  generally 
preferred,  at  the  place  where  it  ceases  to  be  covered  by  the  muscles 
of  the  fore  arm,  opposite  the  radio-carpal  articulation. 

If  the  patient  be  up,  he  should  be  placed  in  the  sitting  posture  ; 
if  in  bed,  he  should  be  upon  his  back,  so  that  he  may  neither  in- 
cline to  the  right  or  left,  and  thus  impede  the  circulation  of  blood 
in  the  arteries.  The  arm  should  be  placed  nearly  in  a  state  of  ex- 
tension and  sustained  in  its  whole  length,  so  that  the  muscles  may 
be  relaxed.  The  fore  arm  should  be  nearly  prone  that  it  may  rest 
upon  the  cubital  edge,  and  the  radial  edge  be  a  little  raised.  Care 
should  be  taken  that  no  bandage  or  clothing  impede  the  flow  of 
blood  in  the  axillae,  at  the  elbow  or  any  other  point.  All  bandages 
should  be  removed  so  that  there  be  the  least  possible  compression. 
By  means  of  these  various  precautions,  we  may  be  certain  that 
there  is  no  foreign  obstacle  to  the  flow  of  blood  through  this  vessel. 

The  artery  of  the  left  side  should  be  felt  by  the  right  hand,  and 
vice  versa  ;  the  four  fingers  placed  parallel  on  the  same  line  should 
be  applied  over  the  track  of  this  vessel ;  the  index  finger  should  be 
nearest  the  hand  of  the  patient;  and  the  little  finger,  applied 
lightly,  should  be  the  first  to  receive  the  impulse  of  the  blood ;  at 
the  same  time  that  the  four  fingers  are  placed  over  the  radial 
artery,  the  thumb,  or  rather  the  palm  of  the  hand  should  rest  upon 
the  dorsal  face  of  the  fore  arm,  thus  affording  a  solid  support  to 
the  fingers  by  which  the  pulse  is  examined.  The  latter  should  at 
first  receive  a  slight  lateral  movement,  in  order  to  ascertain  the  sit- 
uation of  the  vessel.  When  the  fingers  are  all  placed  upon  the 
artery,  the  pressure  should  be  gradually  increased  and  diminished 
several  times  in  succession,  so  as  to  appreciate  the  influence  of  the 
pressure  upon  it,  and  thus  more  easily  ascertain  its  different  quali- 
ties. Twenty  or  thirty  successive  pulsations  should,  in  this  man- 
ner be  examined.  It  is  not  without  advantage  to  examine  the 
pulse  in  the  two  arms  alternately,  or  at  once ;  it  should  also,  in 
particular  cases,  be  examined  in  other  places,  wherever  it  may 
throw  light  upon  the  diagnosis.  It  may  be  also  examined  several 
times,  or  at  least  a  second  time,  before  leaving  the  patient.  How- 
ever minute  these  precepts  may  appear,  they  cannot  be  neglected 
without  inconvenience.  It  is  better  to  accustom  oneself  from  the 
beginning  to  this  mode  of  examining  the  pulse ;  it  may  be  then'done 
without  effort,  and  by  the  simple  effect  of  habit. 

The  changes  effected  by  the  influence  of  disease  upon  the  arte- 
rial pulsations  are  twofold ;  those  which  are  appreciable  at  each 
beat ;  and  those  only  perceptible  by  the  comparison  of  a  certain 
number  with  each  other.  To  the  first  series  belong  quickness  and 
slowness,  hardness  and  softness,  fullness  and  smallness,  feebleness 
and  strength ;  to  the  second,  frequency  and  rareness,  irregularity 


SYMPTOMS.  173 

and  inequality ;  these  different  conditions  of  the  pulse  will  be  suc- 
cessively considered. 

«•  The  pulse  is  quick  (pitlsus  celer),  when  the  arterial  pulsation 
takes  place  with  quickness;  slow  (pulsus  tardus),  on  the  contrary, 
when  it  is  performed  more  slowly  than  in  health. 

Hardness  and  softness  of  the  pulse  are  characterized  by  the 
greater  or  less  degree  of  tension  of  the  artery  during  its  pulsation. 
If  the  beat  gives  the  finger  the  impression  of  a  hard  body  striking 
against  it,  the  pulse  is  hard  (P.  durus);  it  is  soft  (P.  mollis)  when 
it  gently  strikes  the  finger,  and  is  easily  compressible.  The  cordy, 
tense  and  resisting  pulse  are  but  varieties  of  the  hard  pulse.  It 
would  not  be  impossible,  in  old  persons,  to  confound,  with  hardness 
of  the  pulse,  the  resistance  which  depends  solely  upon  ossification 
of  the  arteries.  The  latter  is  easily  recognizable  from  the  firmness 
of  the  parietes  in  the  interval,  and  their  annular  disposition. 

Fullness  and  smallness  of  the  pulse  are  measured  by  the  volume 
which  the  artery  presents  in  pulsating:  the  pulse  is  full  (P.  mag- 
nus)  when  the  artery  is  large  and  full ;  it  is  small  (P.  exilis)  when 
the  pulsations  of  the  artery  are  slender  and  weak.  The/w//,  devel- 
oped, and  great,  are  but  varieties  of  the  large,  pulse ;  the  contracted 
pulse  is  that  which  is  at  the  same  time  small  and  hard. 

The  strong-  pulse  is  characterized  by  its  volume  and  the  force  of 
the  pulsations ;  the  feeble  pulse  by  the  opposite  qualities.  Strength 
of  pulse  (P.  robur)  consists  consequently  in  hardness  and  great- 
ness united;  feebleness  (P.  debilitas),  in  the  smallness  and  softness 
of  the  pulsations.  The  vibrating  pulse,  occurring  in  cardiac  aneu- 
rism, is  a  very  strong  pulse;  the  depressed  pulse,  of  diseases  which 
tend  to  a  fatal  termination,  is  a  very  feeble  pulse. 

Thus  slowness  and  quickness,  softness  and  hardness,  smallness 
and  fullness,  are  the  principal  qualities  of  the  pulse,  which,  by 
their  different  degrees  and  combinations,  constitute  the  varieties 
appreciable  in  each  pulsation. 

There  are  two  other  varieties  which  are  sometimes  confounded, 
bat  ordinarily  very  distinct ;  we  refer  to  the  trembling  pulse  and 
the  pulsus  dicrotus.  In  both  these  cases  the  arterial  pulsation  is 
not  single ;  it  gives  in  the  latter  case  the  sensation  of  a  double 
beat,  which  has  been  compared  to  the  rebounding  of  the  hammer 
on  the  anvil.  In  the  first,  the  pulsation  is,  as  it  were,  uncertain 
or  hesitating;  the  fingers  placed  upon  the  artery  distinguish  at 
each  contraction  of  the  heart  a  trembling  pulsation,  instead  of.  a 
single  beat.  It  is  not  very  uncommon  to  meet  with  persons  in 
whom  it  is  difficult  to  determine  whether  the  pulse  be  redoubled 
or  trembling.  , 

P-  The  frequency  and  rareness  of  the  pulse  are  measured  by  the 
number  of  arterial  pulsations  in  a  given  time.  The  pulse  is  fre- 
quent (P.  frequens}  when  this  is  greater  than  in  health  ;  when  it  is 
less,  the  pulse  is  infrequent  (P.  rarus)  (p.  170).  Of  all  the  qualities 
of  the  pulse,  frequency  is  alone  that  which  can  be  measured  with 
rigorous  precision  by  means  of  the  watch.  This  mode  of  estimat- 
ing the  frequency  of  the  pulse  is  very  useful  to  the  beginner. 
15* 


174  SYMPTOM8. 

who  becomes  thus  accustomed  to  value  it  with  precision ;  but  it 
becomes  unnecessary  to  the  experienced  physician,  who  only  has 
recourse  to  it  in  those  affections,  in  which  it  is  important  to  note 
the  slightest  alterations  in  the  number  of  the  arterial  pulsations 
from  day  to  day.  It  has  been  recommended  by  some  physicians 
to  count  the  pulse  during  a  whole  minute ;  but  a  half  minute  ordi- 
narily suffices,  or,  what,  is  better,  two  quarters,  the  one  serving  to 
correct  the  other.  If  the  frequency  of  the  pulse  be  extreme,  it  will 
be  found  necessary  to  count  the  number  of  pulsations  occurring  in 
five  seconds,  several  times  in  succession,  since  the  cyphers  which 
represent  the  low  numbers  are  nearly  all  monosyllables,  and  may 
be  pronounced  as  rapidly  as  the  most  frequent  pulse,  which  is  not 
the  case  with  the  higher  numbers.  I  have  been  able,  in  this  way, 
to  count  accurately  one  hundred  and  sixty,  one  hundred  and  eighty, 
and  even  two  hundred  pulsations  in  the  minute  ;  while  in  attempt- 
ing to  count  an  entire  minute,  or  even  a  half  minute,  oit  would  be 
found  impossible  to  count  above  one  hundred  and  fifty.  Fre- 
quency of  the  pulse  is  much  more  common  in  disease  than  its  in- 
frequency,  the  latter  rarely  occurring  except  in  certain  periods  of 
some  cerebral  affections,  in  concussion  of  the  brain,  and  in  certain 
organic  lesions  of  the  heart.  We  recollect  a  young  man  at  La 
Charite,  suffering  from  the  latter  disease,  whose  pulse  did  not  ex- 
ceed twenty-eight,  and  sometimes  not  even  twenty-five  pulsations 
per  minute.  Finally,  we  saw  with  Dr.  Meniere,  a  patient  in 
whom  the  number  of  the  arterial  pulsations  was  not  above  fourteen 
per  minute,  this  infrequency  lasting  for  about  twelve  hours.  Fre- 
quency of  the  pulse,  on  the  contrary,  occurs  in  nearly  all  acute 
diseases  and  in  a  great  number  of  chronic  affections.  It  is  almost 
always  accompanied  by  quickness;  sometimes,  but  rarely,  the 
pulse  is  frequent  without  being  quick,  or  quick  and  at  the  same 
time  rarej  when  the  pulse  beats  more  than  eighty  times  per  min- 
ute, it  is  very  difficult  to  judge  of  its  quickness ;  this  is  entirely 
impossible  if  the  pulsations  exceed  one  hundred  and  twenty,  or 
even  one  hundred. 

The  constant  relation  which  exists,  in  health,  between  the  fre- 
quency of  the  respiration  and  that  of  the  pulse,  is  also  generally 
apparent  in  disease,  being  in  the  proportion  of  four  to  one.  We 
are  assured  by  Giannini  that  we  can  thus  by  examination  of  the 
respiration  alone,  and  without  touching  the  patient,  determine  the 
frequency  of  the  pulse  in  all  diseases.  This  assertion  may  be  gen- 
erally correct,  so  far  as  it  relates  to  other  than  thoracic  affections ; 
but  it  presents  numerous  exceptions,  particularly  in  nervous  dis- 
eases, in  which  this  relation  between  the  circulation  and  respiration 
is  often  deranged. 

The  pulse  is  regular  (P.  regularis)  when  the  pulsations  succeed 
each  other  at  equal  intervals ;  it  is  irregular  (P.  irregularis), 
when  the  pulsations  return  at  unequal  intervals.  The  pulse  pre- 
serves its  regularity  in  most  mild  acute  diseases ;  in  persons  whose 
pulse  is  naturally  irregular,  the  arterial  pulsations  may  become 
regular  under  the  influence  of  disease.  Dehaen  observed  two 


SYMPTOMS.  175 

cases  of  this  kind,  noticing  with  anxiety  the  irregularity  which 
appeared  towards  the  period  of  convalescence ;  but  the  patients 
themselves,  who  were  aware  of  the  peculiarity  of  their  natural 
pulse,  viewed  it  as  a  favorable  sign.  Irregularity  of  the  pulse 
may  present  itself  under  various  forms ;  sometimes  one  of  the 
pulsations  appears  to  fail  completely,  this  is  the  intermittent  pulse 
(P.  intermittent)  ;  sometimes,  but  more  rarely,  a  pulsation  occurs 
in  the  interval  between  two  regular  pulsations ;  this  is  called  an 
intercurrent  pulse  (P.  intercidens).  Intermmittence  and  inter cur- 
rence  may  occur  at  equal  intervals ;  but  the  periodicity  rarely  lasts 
more  than  a  few  minutes,  or  at  most,  a  few  hours.  They  are  or- 
dinarily symptomatic  of  an  organic  lesion  of  the  heart ;  they  may 
appear  in  neuroses,  and  in  some  cases  have  appeared  to  be  con- 
nected with  the  presence  of  worms,  or  the  accumulation  of  gas  in 
the  intestinal  canal,  and  the  acute  abdominal  pain  which  occurs  in 
some  intestinal  phlegmasiae  ;  they  appear  in  the  last  few  hours  af 
life  in  most  diseases,  and  finally,  are  not  unaffected  by  cerebral 
influence.  A  professor  of  medicine  at  Bologna,  having  accidentally 
remarked  an  intermittence  in  his  own  pulse,  became  in  conse- 
quence very  anxious  ;  he  was  constantly  placing  his  fingers  upon 
the  artery,  and  observed  at  each  time  that  the  pulse  became  more 
irregular  ;  Morgagni,  whom  he  consulted  upon  the  case,  advised 
him  to  pay  no  attention  to  it,  and  the  intermittence  soon  disap- 
peared. * 

Laennec  was  led,  from  auscultation,  to  admit  false  intermis- 
sions ;  in  these,  the  contraction  still  takes  place,  but  in  so  rapid 
and  feeble  a  manner,  that  no  pulsation  is  felt  in  the  artery ;  in 
such  cases,  there  is  intermittence  of  the  pulse,  and  simply  inequal- 
ity in  the  contractions  of  the  heart. 

During  intermission  of  the  pulse,  the  artery  is  almost  always 
soft  and  unresisting.  Some  physicians  appear  to  have  observed 
cases  in  which  the  artery  was  full  and  tense ;  Laennec  supposed 
that  this  kind  of  intermittence  takes  place  after  ventricular  con- 
traction, and  that  while  it  lasts  there  is  probably  a  permanent  con- 
traction of  these  organs. 

The  equal  pulse  (P.  cequalis),  is  that  in  which  the  pulsations 
resemble  each  other  in  quickness,  fullness,  and  hardness.  The 
pulse  is  unequal  (P.  inequalis),  when  the  pulsations  differ  from 
each  other  in  these  respects. 

The  sense  that  we  have  attached  to  the  words  unequal  and 
irregular,  differs  from  that  given  to  them  by  most  authors,  who 
have  employed  these  two  expressions  indifferently.  We  have 
thought  it  better  to. give  to  each  a  precise  signification,  as  was  the 
case  in  regard  to  respiration ;  we  have  applied  the  word  regularity 
to  the  rhythm,  and  inequality  to  the  other  qualities  of  the  pulse. 

The  pulse  may  cease  to  be  distinct  or  become  confused,  from 
extreme  frequency,  but  particularly  the  feebleness,  irregularity,  and 
inequality  of  the  pulsations.  There  is  no  degree  of  frequency  in 

*  De  sed.  et  Caus.  morb..  Epist.  xxiv.,  art.  20. 


1 76  SYMPTOMS. 

which  the  pulse  may  not  be  counted,  but,  generally,  as  its  frequency 
increases,  it  becomes  more  feeble,  irregular,  and  unequal,  so  that  it 
is  impossible  to  determine  with  accuracy  the  number  of  pulsations 
per  minute.  In  this,  and  in  many  other  cases  in  which  this  de- 
rangement does  not  exist  to  such  a  degree,  an  approximate  evalu- 
ation is  alone  practicable.  The  puTse  may  become  insensible 
(pulsuum  defectio},  like  that  which  occurs  in  the  moribund,  and 
sometimes  after  excessrVe  evacuations  in  persons  who  are  not 
otherwise  seriously  indisposed. 

Is  the  pulse  the  same,  or  does  it  present  remarkable  differences, 
in  the  various  arteries  in  which  it  may  be  examined?  This 
question  comprises  many  others  which  will  be  successively  consid- 
ered. 

The  fullness  and  hardness  of  the  pulse  vary  with  the  size  of  the 
artery  examined ;  the  larger  the  artery,  the  stronger  is  the  pulse. 
Thus  in  cases  in  which  the  arterial  pulsations  become  insensible 
at  the  wrist,  they  are  manifest  at  the  bend  of  the  arm,  and  full  and 
hard  in  the  groins.  For  the  same  reason,  it  may,  and  frequently 
does,  happen,  that  the  strength  of  the  pulsations  differs  in  the  same 
subject  in  two  corresponding  vessels,  the  two  radial  arteries,  for 
example.  This  difference  depends  upon  the  unequal  size  of  this 
artery  in  the  two  arms,  or  the  variable  depth  at  which  it  is  seated. 

Many  physicians  have,  from  certain  cases,  been  led  to  suppose 
tnat,  in  some  cases  of  congestions,  and  in  certain  neurosis,  the 
pulsations  in  the  arteries  which  are  distributed  to  the  affected 
organ,  are  stronger  than  in  those  of  the  rest  of  the  body.  In 
most  cases,  there  is  supposed  to  be  increased  strength  in  pulsations 
of  such  an  artery,  as  the  superficial  temporal,  the  strength  of 
which  in  the  healthy  condition  is  not  appreciated,  and  which,  in 
disease,  is  generally  estimated  rather  from  the  evidence  of  the  pa- 
tient than  that  of  the  senses  of  the  physician ;  now,  the  sensation 
experienced  by  the  patient  may  depend  upon  increased  sensibility 
of  the  parts  surrounding  the  vessels,  as  well  as  the  often  doubtful 
increase  in  the  strength  of  the  arterial  pulsations. 

Do  the  differences  presented  in  the  force  of  the  arterial  pulsa- 
tions in  different  parts  of  the  body,  exist  in  their  quickness,  fre- 
quency, regularity,  or  equality? 

It  is  difficult  to  conceive  how  the  quickness  can  vary  in  the 
different  arteries ;  as,  however,  there  is  a  difference  in  the  con- 
tractility of  the  various  parts  of  the  arterial  system,  it  might  not 
be  impossible  for  the  quickness  with  which  the  pulsation  is 
effected,  to  differ  slightly  in  one  artery  from  that  of  another ;  but 
this  phenomenon,  if  it  exist,  would  be  difficult  to  appreciate.  The 
greater  frequency  of  the  pulse  in  an  artery,  which  some  authors 
pretend  to  have  observed,  cannot  be  admitted ;  in  certain  local 
congestions,  the  pulse  may  seem  to  the  patient  to  beat  oftener  in 
the  inflamed  part  than  elsewhere ;  but  from  a  knowledge  of  the 
laws  of  the  circulation,  we  cannot  admit  the  existence  of  any 
other  pulse  in  the  arteries,  than  that  dependent  upon  the  affiux  of 
blood  propelled  by  the  contraction  of  the  heart ;  now,  as  the  whole 


SYMPTOMS. 


177 


arterial  system  has  a  common  origin  in  this  organ,  it  is  evidently 
impossible  for  the  pulsations  to  be  more  frequent  in  one  artery 
than  another. 

It  has,  however,  sometimes  happened,  that  the  number  of  pul- 
sations in  a  given  time  was  not  the  same  in  the  two  sides ;  a  very 
remarkable  case  is  related  by  Morgagni.  A  child  who  received 
an  injury  in  the  back  by  a  fall  from  a  tree,  was  attacked  with  pal- 
pitation, which  had  not  disappeared  after  a  lapse  of  nine  years, 
and  which  became  particularly  troublesome  at  certain  periods  of 
the  year.  Morgagni  having  seen  this  patient  in  one  of  these 
paroxysms,  found  upon  examination  a  difference  in  the  pulse  of 
the  two  sides:  "  after  a  careful  examination,  he  found  that  the 
arterial  pulsations  upon  the  left  side  were  natural  in  frequency, 
while,  on  the  right,  they  were  less  frequent,  in  the  proportion  of 
three  to  one."  * 

This  fact,  together  with  others  less  authentic,  seem  to  be  di- 
rectly opposed  to  what  we  have  just  said;  but  they  only  prove 
that,  in  some  cases,  the  course  of  the  blood  may  be  temporally 
intercepted  in  one  artery,  without  being  so  in  others,  and  that, 
owing  to  the  transient  obliteration  of  an  artery,  intermissions  con- 
fined to  that  vessel  may  occur.  The  peculiar  lesion  which  pro- 
duces such  an  effect,  at  one  time  interrupting  the  course  of  the 
blood  in  a  vessel,  at  another,  permitting  its  flow,  has  not  yet  been 
ascertained  by  examination  after  death,  the  only  means  of  obtain- 
ing a  satisfactory  explanation  of  this  phenomenon. 

This  differs  from  those  cases  in  which  the  pulsations  of  an 
artery  become  gradually  enfeebled,  and  at  last  entirely  insensible, 
while  those  of  the  corresponding  vessel  preserve  their  normal  con- 
dition. This  difference,  which  has  been  particularly  observed  in 
the  radial  arteries,  is  generally  owing  to  the  development  of  a 
tumor  in  the  vicinity  of  the  arterial  trunk,  compressing  it  the  more 
as  it  increases  in  size,  and  in  some  cases  completely  obliterating 
its  cavity.  This  is  particularly  observed  in  those  cases  of  aortic 
aneurism,  in  which  the  subclavian  artery  is  pressed  by  the  tumor 
against  the  bony  parietes  of  the  chest. 

Such  are  the  principal  changes  effected  by  disease  in  the  arterial 
pulsation;  many  others  have  been  admitted  by  authors;  Galen 
described  more  than  thirty.f  To  these  Solano  of  Lucca,  and  Bor- 

*  De  sedibus  et  Causis,  morb.,  epist.  xxiv.  art.  33. 

f  The  following  are  the  different  varieties  of  pulse  admitted  by  Galen. 

1.  Long:  in  which  the  artery  strikes  several,  or  all  four  fingers. 

2.  Short :  in  which  it  strikes  but  one  or  two  at  most. 

3.  Large:  in  which  it  is  increased  in  diameter. 

4.  Narrow:  in  which  it  is  diminished  in  diameter. 

5.  High  :  that  which  seems  to  raise  itself  to  a  point  in  order  to  strike  the  finger. 

6.  Low :  that  in  which  the  pulsations  are  hardly  perceptible. 

7.  Great :  the  artery  is  increased  in  length,  breadth  and  elevation. 

8.  Small:  one  whose  pulsations  are  slender  and  weak. 

9.  Quick. 

10.  Slow. 

11.  Frequent. 


178  SYMPTOMS. 

due  have  added  still  others,  and  have  asserted  the  existence  of  a 
pulse  peculiar  to  the  affections  or  the  crises  of  each  organ ;  hut  the 
works  of  these  physicians,  in  other  respects,  deserving  of  merit, 
are  generally  considered  as  ingenious  speculations  rather  than  the 
results  of  observation,  All  these  minute  distinctions  of  the  ars 
sphygmica  have  been  justly  abandoned. 

But  it  is  not  only  important  for  the  physician  to  admit  no  alter- 
ations of  the  pulse  but  those  connected  with  conditions  really  ap- 
preciable, such  as  quickness,  fullness,  hardness  and  frequency  ; 
but  it  is  also  necessary  that  these  alterations  should  not  be  noted, 
unless  they  be  very  apparent,  and  such  as  might  easily  be  recog- 
nized by  every  physician  with  senses  fitted  to  receive  these  impres- 

12.  Rare. 

13.  Strong:  that  which  strikes  the  finger  strongly. 

14.  Feeble  :  that  which  strikes  feebly. 

15.  Hard:  the  pulp  of  the  finger  yields  to  the  pulsation. 

16.  Soft :  the  pulsation  yields  to  the  pressure  of  the  finger. 

17.  Full:  the  artery,  full  and  resisting. 

18.  Empty :  the  artery  disappears  and  yields  to  the  fingers  ;  it  has  no  solidity. 

19.  E'jual. 

20.  Unequal. 

21.  Myurus :  so  called  when    it    sinks    progressively,  becoming  smaller   and 

smaller,  like  a  rat's  tail  («v$,  rat;  OVQO,  tail). 

22.  Deficient  Myurus  :  that  which  seems  every  instant  about  to  cease. 

23.  Myurus,  which  diminishes  at  the  two  extremities  :  that  which  strikes  the  first 

and  last  finger  less  sensibly  than  those  between. 

24.  Intermittent:  in  which  the  pulsations  fail  from  time  to  time. 

25.  Intercurrent :  in  which  a  superfluous  pulsation  occasionally  seems  to  occur, 

26.  Deficient:  that  which  ceases  altogether. 

27.  P.  Caprizans :  the  pulsation  is  interrupted  in  the  midst  of  its  diastole,  and 

is  afterward  finished  more  rapidly  than  it  was  commenced. 

28.  P   Dicrotus:  that  in  which  the  finger  is  struck  twice  at  each  pulsation,  like 

the  hammer  on  an  anvil. 

29.  Undulating :  that  which  resembles  in  its  movements  those  of  the  waves. 

30.  Vermicular  :  the  pulsations  resemble  the  progression  of  a  worm. 

31.  P.  Formicans :  these  pulsations  resemble  the  motion  of  an  ant. 
3-2.   Tremulous. 

33.  Palpitating. 

34.  Canvulsive :  the  artery  is  tense  and  hard  like  a  cord. 

35.  P.  Serrinus:  that  which  strikes  the  fingers  unequally,  like  a  saw. 

36.  Ardent :  that   which  seems   to  raise  itself  to  a  point,  striking  the  finger 
promptly  and  forcibly. 

The  Chinese  physicians,  who,  it  is  said,  pretend  to  know  the  nature  and  dura- 
tion of  a  disease  by  the  examination  of  the  pulse  alone,  have  distinguished  still 
other  varieties.  They  admit  a  pecking  pulse,  resembling  the  stroke  of  a  bird's 
beak  ;  another,  similar  to  drops  of  water  falling  through  a  chink,  or  a  frog  en- 
tangled in  the  grass  and  seemingly  unable  to  advance  or  go  back ;  they  have 
also  a  pulse  which  they  compare  to  boiling  water,  and  another  which  is  flutter- 
ing like  a  fish  continually  plunging  and  afterwards  rising  so  slowly  as  to  enable 
one  to  catch  it  by  the  tail.  (Recherches  Hist,  sur  la  Medec.  des  Chinois.)  From 
these  comparisons  we  may  judge  of  the  others. 

Le  P.  Leconte  remarks  that  the  Chinese  physicians  before  visiting  a  patient, 
take  care  to  inform  themselves  of  all  that  he  has  experienced ;  and  afterwards 
having  examined  the  pulse  for  a  long  time,  without  asking  any  question,  they  tell 
with  a  prophetic  air  all  that  they  had  previously  ascertained. 

The  critical  pulses  will  be  enumerated  in  the  article  on  Crisis. 


SYMPTOMS.  179 

sions,  and  capable  of  discerning  them.  The  pulse  is  not  necessarily 
feeble  or  strong,  hard  or  soft,  small  or  full ;  in  many  cases  it  pre- 
sents none  of  these  characteristics  ;  being,  according  to  the  expres- 
sion of  some  authors,  moderate.  We  would  not  insist  on  so  trival 
a  truth,  were  we  not  convinced  that  many  physicians  have  entirely 
neglected  it. 

The  organs  of  arterial  circulation  furnish  also  other  symptoms, 
dependent  upon  their  dilatation  or  aneurismal  rupture ;  as  the 
pulsations  often  felt  in  an  aneurismal  sac,  or  in  tumors  contiguous 
to  healthy  or  diseased  arteries  ;  also  their  hsemorrhages  which  are 
often  fatal,  their  denudation,  wounds,  lacerations,  and  lastly,  their 
ossification,  which  in  old  persons  is  often  manifest  in  the  superfi- 
cial arteries  during  life. 

Auscultation  has  also  been  applied  to  the  study  of  the  arterial 
pulsations,  and  has  furnished  phenomena  not  without  interest.  In 
the  healthy  subject,  if  the  stethoscope  be  applied  over  the  track  of 
an  artery,  a  peculiar  dull  sound  is  heard  which  is  isochronous 
with  the  ventricular  systole.  This  sound,  which  is  caused  by  the 
impulse  of  the  blood  against  the  walls  of  the  vessel,  varies  in  in- 
tensity, according  to  the  size  of  the  artery  and  the  force  with  which 
the  blood  is  propelled.  This  pulsation,  this  dull  sound  may,  when 
heard  in  certain  regions  where  it  does  not  normally  exist,  reveal  to 
the  physician  the  existence  of  a  very  grave  disease,  the  aneuris- 
mal dilatation  of  a  vessel.  So  when  a  simple  or  double  pulsation, 
which  is  circumscribed  more  or  less  forcible,  and  distinct  from  the 
pulsations  of  the  heart,  is  distinguishable  upon  the  anterior  and 
superior  part  of  the  chest,  or  behind,  near  the  vertebral  column, 
aneurism  of  the  aorta  may  be  suspected.  The  existence  of  this 
lesion  becomes  certain  if,  at  the  point  where  the  pulsation  is  per- 
ceptible, there  is  also  an  abnormal  sound,  as  the  rasping  or  bellows 
sounds,  and  the  strength -of  the  pulsation  be  sufficient  to  raise  the 
hand. 

The  bellows  sound  is,  of  all  the  abnormal  sounds  of  the  arteries, 
that  most  commonly  observed.  It  may  be  feeble  or  intense, 
continuous  or  intermittent,  circumscribed  or  diffused ;  it  may  co- 
exist in  the  aorta,  carotids,  subclavian  and  crural  arteries,  the  only 
vessels  of  the  trunk  generally  ausculted.  Sometimes  the  sound  is 
confined  to  one  or  two  arteries.  In  other  cases,  it  is  but  the  reso- 
nance or  expansion  of  the  same  sound  produced  in  the  heart,  and 
it  is  often  produced  in  the  vessel  where  it  is  audible. 

The  bellows  sound  may  exist  in  certain  diseases  of  the  arteries, 
as  ossification  of  their  parietes,  aneurismal  dilatation  and  varicose 
aneurism.  It  may  depend  upon  compression  of  the  vessel  caused 
by  a  voluminous  tumor ;  as  is  observed  in  cases  in  which  the  iliac 
and  hypogastric  arteries  are  compressed  by  an  ovarian  cyst ;  but 
the  arterial  bellows  sound  is  generally  observed  in  chlorosis,  ane- 
mia, and  after  abundant  loss  of  blood,  as  in  uterine  haemorrhage 
and  amputations. 

This  bellows  sound  presents  itself  under  various  forms,  most  of 
which  have  received  distinctive  appellations.  Thus  in  chlorosis,  a 


180  SYMPTOMS. 

sound  is  audible,  particularly  in  the  carotids,  to  which  Bouillaud 
has  applied  the  name  bruit  de  diable,  from  its  resemblance  to  that 
produced  by  a  child's  toy  of  that  name ;  in  other  cases,  it  resembles 
that  of  the  bellows  of  a  forge ;  in  others,  the  cooing  of  a  dove ; 
finally,  a  kind  of  whistling  is  sometimes  perceptible,  which  degen- 
erates, in  some  cases,  into  a  double  toned,  and  slightly  monoto- 
nous, musical  humming.  This  sound  was  called  by  Laennec, 
who  was  the  first  to  describe  it,  a  modulated  whistling,  or  music 
of  the  arteries.  These  last  varieties  of  the  bellows  sound  have, 
like  the  others,  been  principally  observed  in  cases  of  chlorosis, 
anemia,  and  accidentally,  in  some  nervous  subjects. 

Within  a  few  years  many  experiments  have  been  tried  and  de- 
scribed, in  order  to  explain  the  mechanism  of  the  arterial  sounds : 
When  there  is  dilatation  of  a  vessel,  or  roughness  or  unevenness  of 
its  surface,  or  when  a  communication  exists  between  an  artery  and 
vein  by  a  narrow  opening,  or  finally  when  the  calibre  of  a  vessel 
is  diminished  by  any  external  pressure,  the  bellows  murmur  may 
be  naturally  explained  by  the  friction  of  the  blood  against  the 
unequal  surfaces  or  contracted  parietes  of  the  vessel.  But  how 
are  these  various  sounds  produced  in  cases  of  anemia  and  chloro- 
sis? This  question  is  unanswerable.  It  would  appear,  from 
recent  investigations,  that  rapidity  in  the  motion  of  the  blood,  and 
particularly  the  low  density  of  this  fluid,  are  both  conditions 
necessary  to  the  formation  of  these  sounds.  * 

The  symptoms  furnished  by  the  circulation  in  the  capillary 
system  and  veins,  are  much  less  numerous  than  those  observed  in 
the  arterial  circulation. 

C.  The  florid  or  livid  redness  of  the  skin  in  the  whole  or  any 
part  of  the  body,  marbled  appearance,  ecchymoses,  paleness  and 
spontaneous  haemorrhages,  are  all  phenomena  which  belong  to  the 
capillary  circulation. 

Among  these  phenomena,  there  are  those,  such  as  the  florid  red 
color  of  the  skin  and  active  hsemorrhages,  which  almost  al- 
ways coexist  with  an  evident  increase  of  the  vital  forces ;  they 
have  generally  been  considered  as  owing  to  an  increased  ac- 
tion of  the  capillary  vessels.  Others,  as  the  marbled  appear- 
ance, livid  spots  and  passive  haemorrhages,  which  ordinarily 
appear  in  enfeebled  persons,  are  attributed  to  debility  of  the  same 
system. 

The  ecchymoses  following  contusions,  also  appear  to  depend 
upon  the  capillary  vessels,  which  are  moreover  the  seat  of  certain 
traumatic  hsemorrhages,  in  which  the  blood  flows  from  the  surface 
of  a  wound.  In  both  these  cases,  the  haemorrhage  is  owing  to  a 
rupture  or  section  of  the  capillary  vessels,  being  entirely  independ- 
ent of  any  increase  or  diminution  in  the  circulatory  force. 

It  has  been  thought,  by  some  authors,  that  the  blood  may  have 
a  retrograde  course.  The  sudden  paleness  consequent  upon  a 

*Memoire  de  M.  de  La  Harpe,  Archiv.  Gener.  de  Medec.,  1838. 


SYMPTOMS.  181 

lively  emotion  or  sudden  impression  of  cold,  is,  according  to  Spren- 
gel,*  entirely  inexplicable,  unless  a  rapid  retrograde  motion  of 
the  blood  in  all  the  arterial  and  venous  vessels,  be  admitted;  but 
this  phenomenon  may  be  explained  by  supposing  that  the  blood 
contained  in  the  capillary  vessels  is  suddenly  forced  into  the  veins, 
and  that  the  supply  of  arterial  blood  is,  at  least  partially,  cut  off. 

D.  The  venous  circulation  presents  some  very  important  symp- 
toms. The  veins  over  the  whole  surface  of  the  body  may  become 
distended  in  certain  affections,  and  particularly  in  plethora  and 
febrile  heat;  they  disappear,  on  the  contrary,  in  anemia -and  in 
the  chill  which  occurs  at  the  commencement  of  acute  diseases, 
and  in  the  paroxysms  of  intermittent  fever.  Partial  dilatation  of 
the  veins  accompanies  various  diseases,  as  local  congestions  and 
apoplexy,  in  which  the  veins  of  the  neck  are  often  enlarged ;  it  is 
also  observed  in  the  vicinity  of  cancerous  tumors,  particularly 
those  of  the  mammas ;  also  in  cases  of  compression  of  the  veins 
of  a  limb  by  a  tumor:  it  constitutes  one  of  the  most  certain  signs 
of  deep-seated  tumors  of  the  thorax  or  abdomen ;  and,  in  other 
circumstances,  dilatation  of  the  veins  of  the  neck,  head,  chest  and 
superior  extremities,  is  the  only  sign  indicative  of  compression  of 
the  superior  vena  cava.  We  have  referred  above,  to  those  dila- 
tations of  the  subcutaneous  abdominal  veins  frequently  observed  in 
patients  suffering  from  ascites.  There  are  cases  in  which  their 
dilatation  is  considerable,  at  the  same  time  that  the  abdominal 
parietes  are  indurated ;  each  of  these  vessels  seems,  in  such  cases, 
to  be  contained  in  a  solid  canal  whose  angular  sides  and  semicircular 
floor  are  perfectly  distinguished  by  the  finger.  M.  Raynaud,  who  • 
has  called  attention  to  the  dilatation  of  the  superficial  abdominal 
veins,  regards  it  as  indicating  the  existence  of  some  obstacle  to  the 
course  of  the  blood  in  the  vena  porta,  and  as  the  result  of  a  col- 
lateral circulation,  by  means  of  which  the  blood  passes  from  the 
divisions  of  the  inferior,  to  the  superior,  vena  cava.  The  post- 
mortem examination  of  those  who  presented  this  peculiarity,  does 
not  in  all  cases  clearly  reveal  the  impediments  to  the  internal  cir- 
culation, pointed  out  by  M.  Raynaud ;  but  some  lesion  of  the 
abdominal  viscera  is  always  found,  generally  consisting  in  an 
alteration  of  the  liver,  known  as  cirrhosis,  a  species  of  atrophy  in 
which  there  is  probably  some  diminution  in  the  diameter  of  the 
branches  of  the  vena  porta,  and  a  modification  of  the  circulation 
in  some  degree  corresponding  to  the  opinion  of  this  physician. 

In  certain  parts  of  the  body  and  particularly  in  the  lower  limbs, 
in  which  the  venous  circulation  is  rendered  more  difficult  by  the 
laws  of  gravity,  superficial,  sinuous,  knotty  tumors  of  a  bluish 
color  are  often  observed,  which  momentarily  disappear  by  external 
pressure  arid  cold,  and  increase  under  the  opposite  conditions. 
From  these  symptoms  the  affection  of  the  veins  called  varix  is  at 
once  recognizable,  a  disease  in  which  the  length  of  these  vessels 

*  SPRENGEL,  Pathol.  General,  p.  147 
16 


182  SYMPTOMS. 

increases  with  their  size,  as  is  proved  by  their  sinuosities,  a  phe- 
nomenon not  observable  in  the  healthy  condition. 

The  venous  blood  may  pursue  a  retrograde  course,  but  this  can 
only  occur  in  certain  vessels  and  for  a  short  space.  This  phenom- 
enon is  not  uncommonly  observed  in  the  external  jugular  veins,  in 
cases  of'cardiac  aneurism.  At  each  contraction  of  the  heart  the 
reflux  of  blood  can  be  distinguished  by  the  eye,  its  diminishing 
undulations  rising  often  to  the  upper  part  of  the  neck.  This  symp- 
tom is,  by  authors,  termed  a  venous  pulse.  There  is  another 
affection,  in  which  a  retrograde  flow  of  the  blood  in  the  veins  is 
sometimes  noticed  ;  we  refer  to  the  aneurismal  varix.  By  means 
of  the  accidental  communication  occurring  between  two  contigu- 
ous vessels,  a  portion  of  the  arterial  blood  passes  into  the  vein, 
producing  in  it  pulsations  isochronous  with  those  of  the  arteries, 
and  giving  to  the  blood  an  impulse  contrary  to  its  natural  course, 
the  influence  of  which,  however,  is  felt  but  a  few  inches. 

The  manner  in  which  the  blood  escapes  differs  in  wounds  of  the 
arteries,  capillaries  and  veins.  In  the  first  case,  it  issues  with 
force  and  by  interrupted  jets  ;  in  the  second,  it  is  effused  in  small 
quantities ;  in  the  third,  it  may  form  a  continuous  jet,  the  force 
and  volume  of  which  varies  according  to  several  circumstances. 

A  phenomenon  noticed  by  all  authors  is  the  absence  of  haemor- 
rhage in  certain  wounds  of  the  vessels  ;  as  in  lacerated  wounds 
and  those  inflicted  by  fire-arms,  and  more  particularly  after  the 
carrying  away  of  a  limb  by  a  projectile  ;  but  this  is  by  no  means 
always  the  case,  rapid  and  fatal  haemorrhages  having  been  often 
observed,  particularly  in  gunshot  wounds,  if  any  large  artery  have 
been  wounded. 

E.  Having  now  enumerated  the  principal  symptoms  furnished 
by  the  circulation,  it  remains  to  consider  those  furnished  by  the 
blood* itself.  This  subject,  so  interesting  in  a  scientific  point  of 
view,  has  been  almost  wholly  abandoned  since  the  close  of  the  last 
century,  at  which  time,  Parmentier  and  Deyeux  published  the  re- 
sults of  their  experiments  upon  this  fluid,  and  in  which  the  cele- 
brated author  of  the  Nosographic  Philosophique  sapped  to  its 
foundations  the  superannuated  doctrine  of  humorism.  Since  that 
time,  most  physicians,  convinced  that  the  blood  is  insusceptible  of 
any  alteration  in  the  living  body,  have  neglected  to  make  any  in- 
vestigations for  the  purpose  .of  elucidating  this  important  question. 

The  treatise  of  these  two  celebrated  chemists,  however,  from  its 
being  opposed  to  the  ancient  doctrine,  seemed  more  fitted  to  attract, 
than  to  divert,  the  attention  of  the  learned  upon  the  subject  under 
discussion;  and  if  it  had  the  contrary  effect,  the  fault  is  not  so 
much  attributable  to  the  work,  as  to  those  who  lived  at  the  time 
of  its  appearance.  Its  influence  can  only  be  appreciated  by  refer- 
ring to  that  period. 

Its  object  was  to  "  determine,  from  modern  chemical  discoveries 
and  accurate  experiment,  the  nature  of  the  alterations  which  the 
blood  undergoes  in  inflammatory  diseases,  putrid  febrile  diseases 


SYMPTOMS.  183 

and  scurvy."  The  experiments  were  tried;  1,  on  the  blood  of  a 
young  man  affected  with  pneumonia ;  2,  on  that  of  three  individ- 
uals who  presented  symptoms  of  scurvy, ,  connected,  in  two,  with 
general  plethora,  and  with  pain  in  the  side  in  the  other;  3,  on 
the  blood  of  a  certain  number  of  individuals  suffering  from  affec- 
tions vaguely  designated  by  the  term  putrid  fevers,  in  many  of 
which  no  putridity  existed. 

Let  us  suppose  for  a  moment  that  the  results  of  the  observations 
and  experiments  made  on  this  small  number  of  patients  had  all 
been  contrary  to  the  doctrine  previously  admitted,  would  they  suf- 
fice to  overthrow  it?  Certainly  not;  and  we  do  not  hesitate  to 
say,  that  an  opinion  which  had  been  held  for  so  many  centuries, 
and  had  withstood  so  many  contending  systems  and  theories,  de- 
served a  more  thorough  examination  before  discarding  it.  This 
should  only  be  accomplished  by  a  mass  of  well  observed  facts. 
Now,  the  treatise  in  which  it  is  undertaken  to  proscribe  it,  contains 
but  a  single  fact,  and  that  favorable  to  the  opinion  it  combats. 
The  other  experiments  undertaken  in  the  cases  of  scurvy  demand- 
ing bleeding,  and  putrid  febrile  diseases,  -many  of  which  did  not 
present  this  character,  do  not  afford  the  necessary  conditions  to 
serve  as  a  base  for  rigorous  conclusions. 

Let  us  now  pass  to  the  results  of  these  experiments.  1.  Chemi- 
cal analysis  showed  no  difference  between  the  blood  in  pneumonia 
and  that  in  scurvy  ;  but,  without  here  referring  to  the  uncertainty 
inherent  in  chemical  analyses,  the  results  of  which  vary  with  the 
progress  of  the  science,  we  should  recollect  that  there  are  many 
natural,  and,  particularly,  organized,  bodies,  which  are  distinct 
from  each  other  in  their  physical  properties  and  their  action  upon 
the  economy,  although  no  such  difference  is  indicated  by  chemical 
reagents.  This  remark,  the  truth  of  which  is  sufficiently  evident, 
should  suffice  to  put  us  on  our  guard  against  the  hasty  application 
of  chemistry  to  organized  bodies  ;  chemical  analysis  may  show  no 
difference  between  the  blood  of  scorbutic  patients  and  that  of 
persons  suffering  from  an  inflammatory  disease,  although  it  may 
be  as  great  as  between  wholesome  and  poisonous  substances, 
which,  by  chemical  examination,  are  undistinguishable  from  each 
other,  as  the  phlegmonous  and  variolic  pus,  for  example,  which  is 
susceptible  of  producing  very  different  effects  upon  the  economy. 
2.  In  regard  to  the  physical  properties  of  the  blood,  its  consistence 
and  the  formation  of  the  buff,  Parmefitier  and  Deycux  observed 
that  they  were  not  constantly  the  same  in  similar  affections,  and 
were  sometimes  alike  in  diseases  of  an  opposite  nature.  From  the 
careless  manner  in  which  the  diseases  are  characterized  in  this 
treatise,  we  should  be  cautious  in  regard  to  the  conclusions  deduced 
from  these  results. 

Our  only  object  in  thus  appearing  to  criticise  this  treatise,  was 
to  combat  the  consequences  which  have  arisen  from  it,  and  which 
would,  perhaps,  be  disclaimed  by  the  authors  themselves.  They 
justly  called  in  question  an  opinion  the  truth  of  which  had  not  been 
previously  doubted,  and  are  not  responsible  for  errors  which  they 


184  SYMPTOMS. 

did  not  inculcate.  We  have  not  maintained  an  opinion  contrary 
to  that  which  they  expressed ;  we  have  only  proposed  to  bring  the 
question  back  to  where  it  should  be,  and  call  the  attention  of 
faithful  observers  to  a  subject  too  hastily  abandoned.  Without 
Avaiting  for  new  facts  to  shed  more  light  on  this  obscure  point  in 
pathology,  we  will  consider  the  less  doubtful  points  respecting  it. 

We  thus  expressed  ourselves  in  1817,  and  again  in  1824,  respect- 
ing the  hitherto  contested  alterations  of  the  blood  in  the  course  of 
diseases.  Since  that  time  there  has  been  an  entire  change  of  opin- 
ion upon  this  interesting  subject.  The  fluids  of  the  economy,  arid 
particularly  the  blood,  have  been  the  subject  of  curious  researches 
both  by  chemists  and  distinguished  physicians,  which  seem  to 
promise  important  results. 

Some  experimenters,  and  particularly  Rossi  and  Bellingheri, 
have  compared  the  electrical  state  of  the  blood  in  health  and  dis- 
ease ;  but  the  result  of  these  researches,  which  need  to  be  confirmed 
by  others,  has,  as  yet.  afforded  no  useful  indication  in  diagnosis 
or  therapeutics. 

The  blood,  in  disease,  presents  other  more  apparent  changes, 
which  we  shall  proceed  briefly  to  consider. 

While  the  blood  circulates  in  its  vessels,  it  escapes  our  observa- 
tion, and  cannot  consequently  be  submitted  to  examination;  it  is 
only  when  it  flows  from  the  body  that  its  physical  properties 
become  apparent. 

The  qualities  of  the  blood  can  rarely  be  correctly  appreciated 
in  spontaneous  haemorrhages.  This  fluid,  in  issuing  drop  by  drop, 
is  coagulated  in  small  masses,  so  that  its  color  and  consistence  are 
alone  appreciable ;  and  even  these  may  be  with  difficulty  deter- 
mined, if,  as  is  often  the  case,  the  blood  be  mixed  with  other 
matters.  It  is  only  in  blood-letting,  in  which  a  certain  quantity 
of  this  fluid  flows  rapidly  from  a  vessel  of  medium  size,  that  all 
its  qualities  become  appreciable.  The  force  with  which  the  blood 
escapes,  in  the  operation  of  phlebotomy,  deserves  attention,  par- 
ticularly in  its  two  extremes.  Thus,  in  vigorous  subjects,  the  jet 
is  strong  and  continuous,  while  in  those  suffering  from  debility, 
the  blood  flows  slowly,  with  difficulty  and  often  guttatim.  In 
the  cold  stage  of  cholera,  the  slowness  with  which  the  blood  issues 
from  an  incision  of  the  veins,  and  even  arteries,  is  owing  not  only 
to  the  diminished  contraction  of  the  heart,  but  also  to  the  thick- 
ness, viscidity,  and  almost  gelatinous  state,  of  the  blood.  The 
sound  which  is  supposed  to  accompany  the  issue  of  the  blood,  and 
the  quantity  of  froth  which  appears  upon  its  surface  in  the  cup,  it 
is  unimportant  to  notice.  Its  color  can  only  be  distinguished  while 
flowing;  its  contact  with  the  air,  and  particularly  its  separation 
into  different  parts,  soon  produce  marked  changes  in  its  appear- 
ance. It  is  more  red  in  inflammatory  diseases  than  in  adynamic 
affections  and /scurvy,  in  which  it  is  of  a  blackish  hue,  and  dis- 
eases of  debility,  as  chlorosis,  anemia  and  dropsy,  in  which  it  is 
generally  pale.  Some  physicians,  Huxham  among  others,  assert 
that  they  have  perceived  in  the  blood  at  the  moment  of  its  escape 


SYMPTOMS.  185 

from  the  vein  a  fetid  odor  in  those  affected  with  putrid  fever ; 
these  assertions  require  confirmation.  Nevertheless,  such  an  odor 
may  possibly  have  been  noticed,  if,  as  has  recently  been  advanced 
by  Dr.  Bonnet  of  Lyons,  *  the  blood  in  typhoid  fever  contains 
hydrosulphate  of  ammonia,  a  salt  detected  by  Vauquelin  in  putri- 
fied  blood,  and  it  be  true  that  in  some  cases  of  anthracoid 
diseases,  a  spontaneous  development  of  the  hydrosulphuric  acid 
takes  place  in  this  fluid,  f  Pringle  also  recognized  a  putrid  odor 
in  blood  newly  drawn. J  Some  authors  have  asserted  that  this 
fluid  exhales  a  urinous  odor  in  retention  of  the  urine,  but  this 
opinion  has  not  yet  been  verified. 


In  health,  the  blood  has  a  saltis 


i  taste.     It  has  been  supposed, 


by  some  authors,  that,  in  diabetes,  this  peculiarity  was  less  marked, 
and  some  have  asserted  that  the  serum  exhibited  a  sweetish  taste 
(DOBSON).  M.  Guibourt  found,  upon  examination  of  diabetic 
urine,  the  serum  to  possess  the  ordinary  flavor. 

The  temperature  of  the  blood  may  be  modified  in  certain  dis- 
eases. Thus  in  those  affected  with  cholera,  it  was  generally  lower 
by  four  or  five  degrees  (Reaumur)  than  in  other  diseases. 

The  blood,  allowed  to  remain  at  rest  for  a  few  hours,  ordinarily 
separates  into  two  parts :  the  serum,  and  the  coagulum.  The  pro- 
portion, between  the  coagulum  and  serum,  varies  according  to 
different  circumstances,  some  of  which  only  are  known.  The 
serum  is  generally  less  abundant  at  the  commencement  of  inflam- 
matory fevers  and  the  phlegmasiae,  sometimes  being  wholly  absent ; 
the  blood,  in  these  cases,  is  said  to  be  rich  ;  but  towards  the  latter 
periods  of  the  disease,  the  coagulum  becomes  smaller  and  the 
serum  more  abundant,  in  proportion  to  the  number  of  times  blood- 
letting has  been  performed ;  sometimes  also  a  portion  of  the  serurn 
remains  in  the  coagulum,  which  can  only  be  squeezed  out  by  pres- 
sure. In  .these  cases,  the  coaguium  is  softer  than  when  spon- 
taneously disengaged  from  all  the  serum,  and  if  it  exhibit  a  buff, 
this  is  thicker  from  being  infiltrated  with  serum. 

The  quantity  of  serum,  which  is  small  in  robust  persons,  is  con- 
siderable in  those  of  feeble  constitution,  but  particularly  in  those 
affected  with  anasarca  and  chlorosis,  and  also  in  those  who  have 
submitted  to  repeated  blood-letting  :  in  these  cases  the  blood  is  said 
to  be  poor.  In  the  latter,  the  serurn  is  pale  and  free  from  the  citrine 
color  which  is  natural  to  it ;  it  appears  that  the  soluble  salts  which 
it  generally  contains,  are  found  in  less  proportion.  This  has  been 
also  observed  in  Bright' s  disease ;  for  it  results  from  the  experi- 
ments of  Dr.  Christison  that,  from  the  first  period  of  this  affection, 
there  is  a  great  diminution  in  the  density  of  the  serum,  which 
depends  upon  a  more  or  less  considerable  reduction  in  the  propor- 
tion of  albumen  and  salts.  In  consequence  of  this  loss  of  albumen, 

*  Gas.  Medic.,  t.  v.  p.  601. 

f  Nouv.  Biblioth.  Medec. 

j  Maladies  des  Arntees,  p.  388. 

||  Maladies  des  Reins,  t.  1,  p.  2-27. 

16* 


186  SYMPTOMS. 

the  serum  of  the  blood  is  less  coagulable  by  heat,  #  while  an 
opposite  change  takes  place  in  the  urine. 

The  serum  may  also  contain  various  substances  which  can  only 
be  discovered  by  inspection  or  chemical  analysis.  Thus  it  is 
sometimes  of  a  reddish  color,  owing  to  a  portion  of  the  coloring 
matter  of  the  blood  which  it  contains,  a  circumstance,  according 
to  some  authors,  indicative  of  a  state  of -general  debility  or  a 
cachectic  condition.  In  bilious  diseases,  particularly  jaundice, 
the  serum  presents  a  yellow  or  greenish  tint,  which,  in  some 
cases,  precedes  the  change  in  the  color  of  the  skin  by  several 
days,  and  indicates  the  presence,  in  the  blood,  of  the  coloring  mat- 
ters of  the  bile.  According  to  some  chemists,  the  existence  of 
cholesterine  (Boudet)  and  picromel  (Orfila)  has  been  detected  in 
these  cases. 

The  serum  sometimes  presents  a  milky  appearance,  as  was 
observed  by  Christison  in  the  first  period  of  Bright's  disease,  and, 
by  Marshall  Hall,  in  the  blood  which  last  flowed  from  animals 
dying  from  haemorrhage.  Some  physicians  were  for  a  long  time 
deceived  by  this  milky  appearance  of  the  serum,  for  they  supposed 
that  the  blood  contained  this  fluid  in  substance,  or  at  least,  its 
material  principles ;  but  modern  chemists  are  unanimous  in  attrib- 
uting this  peculiar  appearance  of  the  serum  to  the  presence  of 
fatty  matters  in  suspension,  which  are  easily  separated  by  means 
of  ether. 

In  cases  of  urinary  absorption,  and  in  the  first  and  last  periods 
of  the  granular  disease  of  the  kidneys,  the  serum  contains  a  con- 
siderable quantity  of  urea  (Christison,  Rayer,  Rees).  Some  chem- 
ists have  detected  the  same  substance  in  the  blood  in  cholera, 
particularly  in  cases  in  which  the  urinary  secretions  was  suspended 
(Hermann,  f  O'Shaughnessy  f).  It  has  been  recently  advanced 
by  Dr.  Copland,  that  urea  is  found  in  great  abundance  in  the  blood 
of  persons  suffering  from  gout;  §  but  this  assertion  of  the  English 
pathologist  has  not  as  yet  been  confirmed. 

Many  physicians  or  chemists,  among  whom  we  may  mention 
Rollo,  Rees,  Dobson,  M'Gregor,  and  M.  Bouchardat,||  assert  that 
they  have  discovered  in  the  blood  of  diabetic  patients,  a  consider- 
able quantity  of  sugar ;  but  these  results  were  formerly  contested 
by  Nicolas  and  Guedeville,  11  Vauquelin**  and  Wollaston,  ff  and 
more  recently  by  M.  M.  Henry,  Soubeiranjf  and  Guibourt;  |||| 
this  question  is  not  yet  finally  settled. 

The  coagulum  varies  in  its  form,  consistence  and  the  peculiar 

*  Archiv.,  3d  series,  t.  iv.  p.  472. 

f  Bull,  des  Sc.  Med.  de  FERUSSAC,  t.  xxvii.  p.  7. 

j  Gaz.  Medec.,  t.  iii.  p.  109,  1832. 

§  Dictionary  of  Prac.  Med.  art.  Blood. 

||  Revue  et  Journal  des  Connaisances  Medicates,  1839. 

%  Diab.  sucre.     Paris,  1803. 

**  Journal  de  Chimie,  t.  i. 

\\Phil.  Trans.,  1811. 

|j  Journ.  de  Pharm.,  t.  xii.  p.  320. 

IHI  RAYER,  t.  i.  p.  244. 


SYMPTOMS.  187 

appearance  of  its  surface.  Its  form  is  generally  that  of  the  vessel 
into  which  the  blood  is  received,  that  of  a  disc  flat  upon  its  su- 
perior, and  convex  upon  its  inferior,  surface.  In  some  cases,  the 
superior  surface  becomes  concave  from  inversion  of  its  edges  ;  the 
blood  is  then  said  to  be  cupped :  it  is  particularly  when  the  coagu- 
lum  is  small  that  it  presents  this  form,  this  occurring  chiefly  in 
the  second  period  of  inflammations  and  after  repeated  blood-letting. 
Much  importance  has  been  attached  to  the  consistence  of  the 
coagulum.  It  is  generally  firm  in  inflammatory  diseases,  and  in 
robust  subjects ;  it  is,  on  the  contrary,  soft  in  chronic  affections, 
anemia  and  chlorosis ;  it  is  diffluent  in  cases  of  miasmatic  poi- 
soning, in  the  last  stage  of  grave  fevers,  in  certain  eruptive  fevers, 
and,  particularly,  in  confluent  variola,  the  severest  form  of  scar- 
latina, &c.  The  blood,  in  the  cold  or  blue  stage  of  cholera,  is 
black,  viscid,  resembling  current  jelly,  and  reddening  but  slowly, 
by  exposure  to  the  air.  Increase  in  the  density  of  the  clot,  its 
volume,  and  the  small  quantity  of  serum,  indicate  an  abundance 
of  globules ;  paleness  of  the  coagulum,  denotes  a  diminution  of 
the  coloring  principle,  and  consequently  the  iron  with  which  it  is 
combined. 

Is  there  a  condition  of  the  clot  which  is  characteristic  of  any  . 
disease  ?  Can  it  be  admitted,  for  example,  that  a  soft  and  diffluent 
and  curdy  coagulum,  or  a  serum  holding  in  suspension  a  portion 
of  the  coloring  matter  of  the  blood,  are  lesions  characteristic  of 
typhoid  fever  'I  We  think  not.  We  cannot  indeed  regard,  as  pe- 
culiar to  typhoid  fever,  those  alterations  which  often  fail,  particu- 
larly in  the  first  stage  of  this  disease,  the  only  period  when 
blood  -letting  is  generally  practicable,  and  which  we  have  often 
observed  in  other  diseases. 

The  surface  generally  differs  in  appearance  from  the  rest  of 
the  coagulum;  it  is  distinct  in  color  and  nature, -and  of  variable 
thickness.  In  health  and  many  diseases,  this  surface  is  of  a  rosy 
or  vermilion  color  in  the  thickness  of  a  half  a  line  or  a  line.  In 
inflammations,  and  particularly  those  of  several  days'  duration, 
the  blood  is  almost  constantly  covered  with  a  crust  of  a  greater  or 
less  thickness  and  solidity,  often  lardaceous,  to  which  the  term 
inflammatory  crust  or  buff  has  been  applied  (crusta  inflammatoria). 
This  buff  is  so  frequent  in  the  thoracic  phlegmasise  that,  by  many 
authors,  it  has  been  called  the  pleuritic  crust  (crusta  pleuriticd).  It 
also  almost  constantly  exists  in  rheumatic  fever,  and  very  fre- 
quently in  most  acute  diseases  accompanied  with  intense  iever. 
The  buff  does  not,  however,  necessarily  indicate  the  existence  of  a 
phlegmasia,  since  it  occurs  in  the  blood  of  plethoric  persons, 
otherwise  healthy,  and  almost  always  accompanies  pregnancy. 

The  thickness  and  firmness  of  the  buff,  is  generally  in  propor- 
tion to  the  violence  of  the  inflammation  and  the  robustness  of  the 
individual.  It  is  almost  always  of  a  greyish  white  color :  it  is  of 
a  rosy  hue  when  thin,  and  yellow  when  the  serum  in  which  it 
floats  presents  this  color.  By  pressing  it,  a  few  drops  of  serum 
can  generally  be  squeezed  out.  The  formation  and  thickness  of 


188  SYMPTOMS. 

the  buff  do  not  exclusively  depend  upon  the  qualities  of  the  Mood; 
they  are  in  part  owing  to  the  manner  in  which  it  flows  out  and 
the  form  of  the  vessel  into  which  it  is  received.  If  it  flow  slowly, 
it  coagulates  in  falling,  as  has  been  before  remarked,  and  forms  an 
homogeneous  mass  in  which  neither  coagulum,  serum  nor  buff  can 
be  distinguished.  If  it  flow  in  a  jet  from  a  narrow  opening,  the 
conditions  are  more  favorable,  and  a  buff  may  be  formed ;  but  it 
is  generally  thin,  and  the  serum  is  but  imperfectly  separated  from 
the  coagulum ;  if  the  blood  flow  in  a  full  stream  and  from  a  large 
opening,  the  separation  of  the  elements  of  the  blood  takes  place 
more  readily,  and  the  buff  which  it  presents  is  of  a  thickness  and 
consistence  proportionate  to  the  richness  of  the  blood.  These  dif- 
ferences often  appear  at  a  single  bleeding,  if  the  blood  be  allowed 
to  flow  into  several  cups  and  with  unequal  force,  as  often  happens. 
It  is  sometimes  possible  to  judge  from  the  different  thickness  of  the 
buffy  coat  in  various  points  of  its  extent,  that  there  has  been  great 
inequality  in  the  flow  of  the  blood.  Finally,  the  thickness  of  the 
buff  varies  with  that  of  the  clot;  that  is,  the  thickness  of  the  layer 
of  blood  drawn  from  the  veins,  which  depends  upon  the  form  of 
the  receiving  vessel.  If,  for  example,  in  bleeding  a  patient,  four 
ounces  of  blood  be  drawn  into  a  plate,  the  buffy  coat  is  only  one 
or  two  lines  in  thickness ;  half  of  this  quantity,  received  in  a 
tumbler,  would  present  a  buff  five  or  six  lines  in  thickness. 

There  is  another  circumstance  that  exerts  a  marked  influence 
upon  the  thickness  of  the  buffy  coat ;  we  refer  to  the  manner  in 
which  the  separation  between  the  serum  and  coagulum  is  effected. 
This  separation,  which  is  never  absolutely  entire,  so  varies,  that 
in  some  cases,  the  clot  contains  twice  the  quantity  of  serum  as  in 
others.  Now,  the  buff  is  never  so  thick  as  when  infiltrated  with 
serum.  This  disposition  is  at  once  apparent  from  the  transparency 
of  the  buff,  and  the  facility  with  which  the  fluid  escapes ;  if  the 
finger  be  placed  underneath  the  clot  so  as  to  raise  it,  a  multitude 
of  small  drops  are  at  once  visible  on  the  surface  of  the  buff,  which 
rapidly  increase  till  they  unite  by  their  circumferences  and  flow 
of.  We  have  sought  to  ascertain  the  causes  which  produce  this 
retention  of  the  serum  by  the  coagulum;  but  from  the  different 
experiments  which  we  have  made  by  varying  the  form  and,  in 
some  cases,  the  temperature  of  the  vessel  into  which  the  blood  was 
received,  and  taking  into  account  the  size  of  the  opening  in  the 
vein,  the  force  with  which  the  blood  flowed  out,  and  the  nature  of 
the  affection  from  which  the  patient  suffered,  we  have  been  able 
as  yet  to  learn  nothing  respecting  the  conditions  necessary  to  the 
production  of  this  phenomenon. 

The  existence  of  a  buffy  coat,  according  to  most  authors,  indi- 
cates an  increase  in  the  proportion  of  fibnne;  according  to  others, 
a  modification  of  the  albumen ;  there  are  also  many  who  attribute 
it  to  a  matter  spontaneously  coagulable.  The  production  of  this 
phenomenon  is  enveloped  in  much  obscurity. 

The  blood  may  contain  various  deleterious  principles,  some  of 
which  are  discoverable  by  chemical  reagents;  thus,  Urfila  has  been 


SYMPTOMS.  189 

able  to  detect  the  presence  of  arsenious  acid  in  the  blood  of  those 
poisoned  by  this  substance.  There  are  other  deleterious  princi- 
ples which  can  alone  be  suspected  to  exist  in  the  blood  :  thus  in 
the  inoculation  of  the  contagious  and  eruptive  diseases,  every 
thing  indicates  that,  between  the  insertion  of  the  virus  and  the 
development  of  the  symptoms,  the  blood  undergoes  some  alteration, 
the  detection  of  which  is  beyond  the  reach  of  physical  or  chemi- 
cal exploration.  The  presence  of  the  virus  of  rubeola  in  this 
liquid,  would  have  been  shown  by  the  experiments  of  Fr.  Home 
and  Sparanza,  who  inoculated  rubeola  with  the  blood  of  those 
affected  with  this  disease,  if  these  experiments  had  been  repeated 
a  sufficient  number  of  times,  by  different  experimenters  with  the 
same  success,  and  with  all  the  necessary  precautions. 

If,  as  is  proved  by  the  observations  of  modern  chemists,  the 
blood  in  its  normal  condition  contain  oxgyen,  azote  and  carbonic 
acid  in  a  free  state,  it  is  probable  that  many  alterations  in  this 
fluid  may  depend  upon  a  change  in  the  normal  proportion  of  these 
gases.  Dr.  Clanny  has  pretended  that  the  blood  in  typhoid  fever, 
contains  less  carbonic  acid,  and  consequently  advises  the  use  of 
Seltzar  water.  #  But,  on  the  one  hand,  the  opinion  of  Dr.  Clanny 
upon  this  alteration  of  the  blood  needs  confirmation ;  and,  on  the 
other,  respecting  the  curative  method  proposed  by  him,  we  may 
remark,  that  having  treated  a  great  number  of  patients,  at  La 
Charite,  by  the  exclusive  employment  of  gaseous  drinks,  no  more 
cures  were  obtained  by  these,  than  by  cooling  and  acidulated 
drinks. 

Such  are  the  principal  alterations  furnished  by  the  blood  in  dis- 
ease ;  if  there  be  many,  which  are  doubtful,  there  are  others, 
too  evident  to  admit  of  question.  All  physicians  are,  at  the  pres- 
ent day,  convinced  of  the  necessity  of  studying  these  alterations, 
which  are  already  of  interest,  and  promise  henceforth  results  of 
immeasurable  importance. 

The  microscopical  characters  of  the  blood,  both  in  health  and 
disease,  have  also  been  recently  investigated.  But  as  no  positive 
results  have  yet  been  obtained  from  these  researches,  as  experi- 
menters have  arrived  at  different  and  often  contradictory  conclu- 
sions, we  abstain  from  giving  opinions  which  need  confirmation. 
We  shall  only  premise  to  those  engaged  in  these  investigations,  that 
the  blood-globules  readily  undergo  an  alteration  during  the 
formation  of  the  clot,  and  that  hence  it  becomes  necessary  to  defi- 
brinate  the  blood  as  it  issues  from  the  vein ;  in  this  way  a  fluid  may 
be  obtained,  which  is  easily  preserved  for  a  considerable  time,  and 
in  which  the  properties  of  the  globules  remain  unchanged. 

$  I.  Circulation  of  Lymph.  The  phenomena  which  occur  in 
the  lymphatic  vessels,  it  is  rarely  possible  to  appreciate.  The 
redness  which  sometimes  makes  its  appearance  in  their  course, 
and  their  hard  and  knotty  feel,  are  symptoms  of  their  inflamma- 

*  A  Lecture  upon  typhoid  fever.     Lond.  1828. 


]  90  SYMPTOMS. 

tion.  Many  cases  have  been  cited  in  which  they  presented  dila- 
tations similar  to  those  in  varicose  veins.  But,  generally,  the 
alterations  of  lymphatic  vessels  are  not  appreciable  till  after 
death. 

The  lymphatic  glands  which,  with  the  vessels  of  the  same 
name,  concur  in  the  circulation  and  elaboration  of  the  lymph, 
present  symptoms  more  apparent.  They  often  become  increased 
both  in  volume  and  sensibility,  a  phenomenon  to  which  the  term 
engorgement  has  been  applied,  and  which  may  appear  in  an  acute 
or  chronic  form.  This  engorgement  of  the  lymphatic  glands 
almost  always  follows  a  lesion  of  some  part,  in  greater  or  less 
proximity,  and  more  frequently,  the  application  of  virus  or  some 
acrid  substance  to  the  parts  from  which  the  lymphatic  vessels,  be- 
longing to  these  glands,  take  their  rise.  In  erysipelas  of  the  face, 
the  submaxillary  glands  are  the  seat  of  a  painful  swelling,  which 
also  occurs  in  some  cases  of  angina,  and  particulary  those  termed 
couenneuses.  Chronic  eruptions  of  the  scalp,  the  difficult  extrac- 
tion of  a  tooth,  and  dental  caries,  are  frequent  causes  of  a  chronic 
and  often  circumscribed  engorgement  of  the  same  glands  and  those 
upon  the  side  of  the  neck.  Acute  engorgement  of  the  axillary 
glands,  ordinarily  arises  from  an  excoriation,  a  prick  of  the  fingers, 
particularly  if  the  wound  be  inoculated  with  putrid  matter,  as 
is  too  often  the  case  in  those  who  wound  themselves  in  dissecting, 
or  who,  having  a  scratch  or  excoriation  upon  the  hand,  bring  it  in 
contact  with  an  irritant  and  septic  fluid,  as  pus  or  sanies.  In 
other  cases,  the  glandular  engorgement  is  owing  to  a  phlegmasia, 
wound,  ulcer  or  blister  upon  the  corresponding  side  of  the  chest. 
In  nursing  women,  diseases  of  the  mammary  gland  are  a  frequent 
cause  of  a  painful  engorgement  in  the  axillae.  The  glands  of  the 
groin,  also,  become  frequently  inflamed,  and  from  the  precise  seat 
of  the  engorgement,  we  may  often  determine  whether  it  be  symp- 
tomatic of  a  lesion  of  the  genital  organs,  the  corresponding  limb 
or  the  inferior  part  of  the  trunk.  If  it  exist  in  the  internal  part  of 
the  groin,  some  disease  of  the  genital  organs  should  be  at  once 
suspected,  because  it  is  in  this  part.of  the  inguinal  region  that  the 
lymphatic  vessels  which  arise  in  the  sexual  organs,  all  centre.  If 
the  engorgement  occur  at  the  inferior  and  external  part  of  the 
groin,  it  generally  depends  upon  a  lesion  of  the  lower  limb,  as  a 
wound  or  excoriation  upon  one  of  the  toes,  produced  by  walking 
or  some  other  cause.  If  it  is  the  superior  lymphatic  glands  that 
are  inflamed,  the  cause  must  be  sought  in  the  abdominal  parietes. 
Lastly,  if  the  phlegmasia  is  confined  to  the  external  side  of  the 
inguinal  region,  the  corresponding  thigh,  which  is  generally  the 
seat  of  the  cause  which  produces  the  engorgement,  should  be 
examined. 

It  seems  then  that  inflammation  of  the  lymphatic  ganglia  gen- 
erally succeeds  an  evident  cause  of  irritation,  more  or  less  remote. 
But,  there  are  cases  in  which  the  glands  become  inflamed  and 
painful,  independently  of  any  perceptible  alteration  of  texture  or 
color  in  the  neighboring  parts.  The  occurrence  of  a  glandular 


SYMPTOMS.  191 

engorgement  under  these  circumstances,  when  accompanied  with 
fever,  generally  indicates  the  speedy  development  of  erysipelas 
upon  some  not  far  distant  part  of  the  integuments ;  thus  if  it  be 
the  submaxillary  or  cervical  glands  that  become  affected,  the 
erysipelas  will  manifest  itself  upon  the  head ;  if  the  axillary 
ganglia  or  those  of  the  groin,  its  appearance  upon  the  superior  or 
inferior  limb  may  be  expected.  In  those  cases  where  a  glandular 
engorgement  precedes  the  inflammation  which  it  ordinarily  accom- 
panies as  a  secondary  phenomenon,  it  is  probable,  that,  although 
there  be  no  change  perceptible  to  the  eye,  or  pain  experienced  by 
the  patient,  a  modification  already  exists  in  the  capillaries  of  the 
lymphatic  or  circulatory  system,  the  first  effect  of  which  is  inflam- 
mation of  the  glands. 

When  the  swelling  of  the  subcutaneous  and  subaponeurotic 
glands  is  very  considerable,  occupying  many  at  once,  and  the  in- 
flammation of  which  extends  to  the  surrounding  cellular  tissue, 
the  inflammatory  tumor  is  called  a  bubo,  a  word  particularly 
applied  to  engorgements  in  the  groin  and  axillary  regions,  and 
sometimes  to  those  of  the  neck  and  ham.  When  primary,  a  rare 
circumstance,  or  depending  upon  a  non-specific  irritation,  more 
or  less  remote,  they  are  called  simple.  They  are  termed  syphilitic 
and  pestilential  when  caused  by  the  virus  which  constitutes  these 
two  affections :  the  former,  are  generally  seated  in  the  groin  and 
connected  with  the  existence  of  chancres  upon  the  external  organs 
of  generation ;  the  latter,  which  are  particularly  observable  in  the 
East,  may  appear  wherever  a  certain  number  of  glands  exist 
grouped  together,  as  in  the  groins  and  axillae,  sometimes  in  the 
ham  and  cervical  region,  and  more  rarely  in  the  cheeks ;  it  would 
appear  from  the  examination  of  bodies  after  death,  that  the  deep 
seated  glands,  in  front  of  the  vertebral  column,  often  participate  in 
the  engorgement  of  the  superficial  glands.*  Syphilitic  and  pestilen- 
tial buboes  frequently  terminate  by  suppuration.  This  termination 
is  rare,  on  the  contrary,  in  simple  buboes.  When  chronic  engorge- 
ment of  several  glands  exists  simultaneously  in  different  regions, 
presenting  a  chronic  form,  it  denotes  some  constitutional  affection, 
generally  a  scrofulous  taint. 

A  peculiar  symptom  sometimes  presented  by  the  lymphatic  ves- 
sels and  glands,  is  a  discharge  of  colorless  fluid,  following  suppu- 
ration or  wounds  of  their  tissue,  which  in  some  cases  persists  for  a 
long  time,  as  is  occasionally  observed  after  syphilitic  inflammation 
of  the  inguinal  glands. 

In  regard  to  the  alterations  of  the  lymph,  its  consistence,  acri- 
mony, &c.,  they  have  never  been  definitely  determined :  analogy 
would  lead  us  to  suppose  that  this  fluid,  like  all  those  which  enter 
into  the  composition  of  the  human  body,  is  susceptible,  in  disease, 
of  undergoing  various  modifications ;  but  these  modifications  have 
not  hitherto  been  the  subject  of  serious  investigation,  being  a 
branch  of  research  so  entirely  new  and  the  difficulties  with  which 

*  Dela  Peste  orientate,  etc.,  par  BULARD.     Paris,  1839. 


192  SYMPTOMS. 

it  is  surrounded  so  great,  that  its  elucidation  can  only  be  effected 
by  means  of  experiments  performed  upon  healthy  and  diseased 
animals. 

SECTION     FOURTH. 

Symptoms  furnished  by  Animal  Heat. 

The  faculty  by  which  the  human  body,  in  the  healthy  condition, 
is  enabled  to  maintain  a  uniform  degree  of  heat,  whatever  be  the 
temperature  of  the  surrounding  medium,  becomes  still  more  appa- 
rent in  disease.  In  health,  the  heat  of  the  body  is  always  in- 
creased to  a  certain  extent  when  exposed  to  a  temperature  higher 
than  its  own  ;  it  becomes  diminished  under  the  opposite  conditions. 
In  disease,  on  the  contrary,  the  body  may  become  chilled  notwith- 
standing the  employment  of  warm  applications;  the  heat  may  also 
become  burning,  without  being  affected  by  the  ingestion  of  cool 
drinks,  or  the  removal  of  clothing.  Under  other  circumstances, 
patients  become  morbidly  susceptible  of  the  influence  of  cold  and 
heat. 

The  appreciation  of  morbid  heat,  as  of  many  other  symptoms, 
requires  on  the  part  of  the  physician  long  experience,  which  can 
only  be  attained  by  close  observation  and  the  frequent  comparison 
between  normal  and  abnormal  heat,  in  the  various  conditions  of 
health  and  disease.  The  best  instrument  that  can  be  employed,  is 
the  hand.  We  are  sometimes  enabled  by  the  thermometer  to 
ascertain  the  exact  degree  of  the  heat  of  the  body;  but  this  instru- 
ment is  entirely  unfitted  to  show  the  other  modifications  sometimes 
presented  by  abnormal  heat.  In  many  cases,  indeed,  we  are 
enabled  to  perceive  a  manifest  increase  of  temperature,  although 
that  indicated  by  the  thermometer  is  not  above  the  usual  standard 
of  the  blood  in  health.  This  is  particularly  evident  from  the 
experiments  of  Hunter,  who,  having  produced  an  artificial  inflam- 
mation in  the  vagina  and  rectum  of  an  ass,  in  the  chest  and 
abdomen  of  a  dog  and  slut,  was  unable,  in  any  of  these  cases,  to 
distinguish  by  means  of  the  thermometer  the  slightest  elevation  of 
temperature,  whilst  its  increase  was  perceptible  to  the  touch.*  In 
order  to  appreciate  the  varieties  presented  by  the  animal  heat,  the 
hand  employed  should  be  moderately  warm ;  it  should  be  applied 
successively  to  various  parts,  and  particularly  to  the  extremities 
of  the  limbs,  face,  chest,  abdomen,  and  over  the  region  which 
appears  to  be  the  seat  of  the  disease  or  predominant  symptoms ;  it 
should  be  allowed  to  remain  in  contact  with  each  of  these  parts, 
for  twelve  or  fifteen  seconds,  in  order  to  ascertain  if  the  sensation 
transmitted  to  it,  remains  the  same  or  differs  by  prolonged  contact. 

It  has  been  said  that  the  animal  heat  is,  generally,  more  consid- 
erable in  children  than  adults ;  that  it  is  always  less  in  the  morn- 
ing, becomes  sensibly  increased  in  the  middle  of  the  day,  and  is 

*  HUNTER  (John),  .4  Treatise  on  the  blood  and  inflammation.  Lond.  1794,  4lo. 


SYMPTOMS.  193 

more  elevated  in  the  evening  than  at  any  other  period;  that  during 
calm  sleep,  the  temperature  is  diminished  by  four  or  five  degrees, 
and  at  the  moment  of  awaking,  is  sensibly  increased,  &c. ;  but  to 
all  these  rules  established  by  semeiologists,  there  are  numerous 
exceptions. 

There  are  four  principal  modifications  presented  by  the  heat  in 
disease,  it  may  be  increased,  diminished,  abolished  or  perverted. 

A.  The  heat  may  be  more  or  less  increased  in  different  diseases, 
or  in  different  periods  of  the  same  disease.  Between  the  slight 
heat  which  occurs  in  many  light  affections,  and  the  burning  heat 
observed  in  the  most  violent  febrile  diseases,  there  are  various 
shades. 

In  some  cases,  the  heat  is  alone  sensible  to  the  patient,  in  others, 
it  is  perceptible  to  the  hand  of  the  physician,  or  can  be  measured 
by  means  of  the  thermometer.  Some  experimenters  assert  that 
they  have  been  thus  enabled  to  distinguish  an  elevation  or  diminu- 
tion of  temperature  of  several  degrees.  Thus  in  some  cases  of 
typhoid  fever,  the  temperature  has  been  known  as  high  as  from 
33°  or  34°  c.  to  40  or  41°,  *  while  in  cholera,  according  to  the 
experiments  made  at  Vienna,  the  temperature  of  the  feet  was  as 
low  as  14°,  Re.,  and  that  of  the  tongue  15°.  There  is  no  disease 
in  which  the  temperature  is  so  low  as  in  cholera,  f 

The  heat  may  be  general  or  partial ;  in  the  first  case,  it  may  be 
distributed  equally  over  the  whole  body,  or,  as  is  most  common, 
be  more  elevated  in  certain  regions.  When  the  heat  is  confined  to 
a  single  region,  it  is  sometimes  in  the  diseased  organ  itself  that  it 
appears,  and  sometimes  in  a  part  more  or  less  remote,  as  the  head, 
in  certain  affections  of  the  stomach,  and  the  palms  of  the  hands 
in  some  diseases  of  the  lungs.  The  skin,  which  covers  a 
phlegmon,  is  almost  always  very  warm,  and  the  heat  of  the  fore- 
head is  often  more  or  less  elevated  in  cephalgia.  It  has  been 
asserted  that  the  integuments  of  the  abdomen  and  thorax  also 
become  thus  affected  in  the  phlegmasiss  of  the  organs  contained  in 
these  cavities,  as  is  the  case  with  the  skin  of  the  forehead  in  some 
cerebral  affections  ;  but  here  the  analogy  is  fallacious.  In  most  dis- 
eases, and  particularly  febrile  affections,  the  degree  of  heat  sensible 
to  the  hand,  is  greater  in  the  regions  of  the  chest  and  abdomen, 
than  at  the  extremities :  this  difference  even  exists  in  those  cases 
in  which  the  seat  of  the  disease  is  remote  from  these  two  cavities  ; 
and  in  the  phlegmasiae  of  the  lungs,  the  integuments  of  the  abdo- 
men are  as  warm  as  those  of  the  thorax. 

The  heat  presents  analogous  varieties,  in  relation  to  its  type :  it 
sometimes  continues  uninterruptedly  during  the  whole  course  of  a 
disease;  it  sometimes  reappears  periodically,  as  in  intermittent 
fevers,  or  at  irregular  intervals,  being  of  transient  duration 
in  females  suffering  from  disordered  menstruation,  and  nervous 

*BOUILLAUD,  CUn.  de  la  Charite,  t.  1,  p.  294. 
•f  GA.YMARD  and  GERA.RDIN,  p.  121. 

J7 


194  SYMPTOMS. 

persons;  in  these  cases  it  comes  on  in  flushes,  according  to  the 
common  expression;  these  flushes  ordinarily  occur  in  the  face; 
they  are  accompanied  by  redness  of  the  part,  and  are  frequently 
followed  by  gentle  perspiration.  The  partial  and  transient  heat 
which  is  sometimes  felt  in  different  parts,  moving  rapidly  from  one 
to  another,  has,  by  authors,  been  termed  nervous  or  erratic. 

The  heat,  in  disease,  presents  still  other  differences  in  relation  to 
the  peculiar  character  which  it  offers;  it  sometimes  resembles  that 
of  a  healthy  person  when  warm  :  this  is  called  free  heat;  when 
accompanied  by  moisture,  like  that  felt  by  a  person  after  a  warm 
bath,  it  is  called  moist ;  if  the  skin  have  lost  its  suppleness  and 
ordinary  degree  of  moisture,  the  heat  is  termed  dry  ;  it  is  burning, 
when  there  is  dryness  together  with  a  high  degree  of  temperature  ; 
it  is  acrid  and  pungent,  when  it  conveys  to  the  fingers  a  disagree- 
able sensation,  well  expressed  by  the  epithet,  and  which  instead 
of  diminishing,  increases  by  prolonged  contact,  and  which  con- 
tinues for  some  time  after  this  has  ceased.  Some  authors  have 
described  other  varieties,  which  they  have  termed  hectic,  and  sep- 
tic, heat ;  but  these  secondary  shades  are  of  difficult  and  uncertain 
appreciation,  and,  as  it  is  impossible  to  give  an  idea  of  them  by 
words,  we  shall  only  mention  them  as  belonging,  the  one  to  hectic 
fever,  the  other,  to  parts  affected  with  gangrenous  inflammation. 

B.  Diminution  of  heat,  or  cold,  presents  the  same  varieties  in  re- 
lation to  its  intensity,  seat,  type,  and  peculiar  character. 

Cold  may  be  appreciable  by  the  physician,  or  be  only  sensible  to 
the  patient,  in  both  cases  its  intensity  may  vary.  Coldness  is  a 
simple  sensation  of  cold ;  horripilation,  a  sensation  accompanied 
with  bristling  of  the  hairs  over  the  body  (goose  flesh)  ;  when 
attended  with  an  involuntary  tremor,  it  is  called  a  rigor.  A  chili 
may  be  general  or  partial,  external  or  internal,  transient  or  con- 
tinual, with  or  without  exacerbation.  .  Senac  speaks  of  a  fever 
patient  whose  arm  alone  was  cold.  In  regard  to  its  peculiar  char- 
acter, it  may  be  stinging,  icy,  or  similar  to  that  experienced  by  a 
healthy  person  when  exposed  to  the  cold  air. 

Partial  cold  almost  always  affects  the  extremities,  end  of  the 
nose,  back  and  loins.  It  is  also,  but  very  rarely,  seated  in  the 
affected  organ,  as  is  sometimes  observed  in  chronic  rheumatism. 

A  chill  of  greater  or  less  intensity  generally  marks  the  com- 
mencement of  most  of  the  phlegmasiae.  If  violent,  and  occurring 
in  a  person  previously  in  perfect  health,  it  indicates,  particularly 
in  the  winter  and  spring,  when  these  diseases  are  most  frequent, 
an  attack  of  pleuro-pneumonia,  and  should  lead  the  physician  to 
fear  its  development,  even  before  the  appearance  of  any  other  local 
sign,  and  when  there  are  considerable  disorder  of  the  stomach,  or 
brain,  to  direct  our  suspicions  elsewhere.  This  phenomenon  has 
alone  enabled  us,  in  many  cases,  to  prognosticate  an  inflammation 
of  the  lungs,  which  did  not  become  distinctly  apparent  till  after  one 
or  two  days  of  fever. 

Intermittent  fever  commences  also  by  a  rigor ;  but  this  is  gen- 


SYMPTOMS.  195 

erally  accompanied  by  a  general  tremor,  which  is  not  commonly 
observed  at  the  commencement  of  the  phlegmasise.  When  the 
phlegmasia  terminates  in  suppuration,  irregular  chills  supervene, 
which  proceed  from  the  inflamed  organ  (Landre-Beauvais).  Rigor 
is  often  the  index  of  an  abundant  suppuration,  and,  according  to 
Baillou,  the  absorption  of  pus  into  the  blood.*  Dance  observed 
the  same  phenomenon  in  phlebitis,  when  the  pus  had  made 
its  way  into  the  circulatory  torrent.  In  these  cases,  there  are  vio- 
lent chills,  which,  in  some  subjects,  recur  with  a  kind  of  periodi- 
city, as  in  intermittent  fever. 

In  a  great  number  of  cases,  there  is  an  alternation  of  cold  and 
heat  in  the  same  individual,  the  chill  generally  occurring  first, 
followed  by  the  heat;  the  contrary  is  sometimes  observed.  Dimi- 
nution and  increase  of  temperature  often  succeed  each  other  many 
times  within  a  short  period. 

C.  The  complete  abolition  of  heat  only  occurs  in  cases  of  freez- 
ing which  may  be  partial  or  general ;  it  is  probable  that  the  tem- 
perature is  nearly  as  low,  even  in  parts  susceptible  of  complete 
restoration.     However,  we  know  of  no  fact  of  this  kind  in  which 
the  degree  of  heat  was  measured  by  the  thermometer. 

D.  The  heat  is  perverted  in  all  cases  in  which  the  patient  com- 
plains of  a  sensation  of  cold  in  a  part  which  is  evidently  warm,  or 
a  sensation  of  warmth  in  a  part  which  is  cold.     The  latter  phe- 
nomenon often  occurs  in  dry  gangrene  of  a  limb.     The  patient 
complains  of  burning  heat  in  the  affected  part,  while  to  the  assis- 
tants it  feels  cold.     To  this  disorder  of  the  heat  may  be  referred 
those  sensations  of  external  and  icy  coldness  and  internal  heat, 
sometimes  simultaneously  felt,  and  vice  versa.     We  have  seen  at 
La  Charite,  in  one  of  the  wards  of  Lertninier,  a  case  still  more 
extraordinary,   that   of  a  young  man  who  had   been  for  some 
time  suffering  from  intermittent  fever.     At  the  moment  that  he 
experienced  the  rigor,  that  is,  a  sensation  of  cold  with  general 
tremor,  his  skin  became  red,  warm,  and  covered  with  a  profuse 
sweat.     This  singular  phenomenon  occurred  during  several  succes- 
sive paroxysms. 


SECTION    FIFTH. 
Symptoms  furnished  by  the  Exhalations  and  Secretions. 

The  act  by  which  certain  fluids  are  separated  from  the  blood  by 
means  of  the  various  organs,  is  called  secretion.  Of  these,  there 
are  two  kinds ;  those  that  occur  in  all  parts  of  the  body,  and  par- 
ticularly on  the  free  surface  of  different  membranes,  and  are  com- 

*  Batto.  Gmstt/.,  lib.  1,  p.  110. 


196  SYMPTOMS. 

prised  under  the  term  exhalations  ;  and  those,  which  have  partic- 
ular organs,  furnished  with  excretory  ducts,  and  which  have  been 
more  properly  called  secretions.  These  will  be  considered  succes- 
sively. 

§  1st.    Exhalations. 

The  exhalations  not  only  serve  the  purpose  of  maintaining  the 
suppleness,  preventing  adhesion,  or  favoring  the  motion  of  the 
membranous  surfaces  upon  each  other  ;  they  act  a  still  more  im- 
portant part  in  the  general  equilibrium  ;  they  prepare,  by  elabora- 
tion of  the  fluids,  materials  for  nutrition.  We  shall  not  attempt  to 
follow  physiologists  in  their  discussions  upon  the  form  and  modus 
operandi  of  the  exhalent  organs  ;  the  exhalent  fluids,  alone  appre- 
ciable to  the  senses,  are  what  particularly  should  claim  the  atten- 
tion of  the  physician. 

The  symptoms  which  depend  upon  the  exhalations  may  be 
divided  into  three  groups ;  to  the  first,  belong  the  various  changes 
which  supervene  in  the  natural  exhalations,  as  those  which  occur 
in  health  ;  to  the  second,  may  be  referred  the  phenomena  peculiar 
to  the  morbid  exhalations ;  we  class,  in  the  third  series,  all  that 
relates  to  artificial  exhalations.  To  the  first  series,  belong  the 
cutaneous,  mucus,  serous,  synovial,  fatty,  menstrual,  and  certain 
other  natural,  sanguineous,  exhalations  ;  to  the  second,  the  exhala- 
tion of  blood,  pus,  and  some  other  fluids  ;  the  exhalation  furnished 
by  blistering  and  cauteries,  will  be  ranked  in  the  third  series. 

A.    Natural  Exhalations. 

1.  The  cutaneous  exhalation,  or  perspiration,  in  health,  is  con- 
stant, gentle,  and  equal  in  all  parts  of  the  body.  It  becomes,  at 
intervals,  more  abundant,  constituting  sweat,  which  is  always  ex- 
cited by  an  evident  cause,  as  heat  of  the  atmosphere,  exercise,  a 
violent  emotion,  &c. 

In  disease,  this  exhalation  may  be  undisturbed,  preserving  the 
suppleness  peculiar  to  the  cutaneous  surface.  When  moderately 
increased,  it  produces  moisture  (mador)  upon  the  skin.  If  the  in- 
crease is  more  considerable,  so  that  the  fluid  appears  in  drops  upon 
the  surface  of  the  skin,  and  moistens  the  clothes,  it  is  called  sweat 
(sudor).  This  may  be  general,  or  partial ;  in  the  first  case,  it  is 
everywhere  equal,  as  towards  the  decline  of  acute  affections; 
sometimes  it  is  more  abundant  on  the  neck,  chest,  and  forehead, 
as  is  observed  in  phthisis.  W7hen  partial,  it  is  often  confined  to  the 
palms  of  the  hands,  epigastrium  and  forehead.  Sweating  of  the 
hands  and  feet  is  habitual  in  some  persons.  Its  sudden  suppres- 
sion has  always  been  thought  to  be  the  cause  of  severe  accidents, 
as  would  appear  from  the  observations  recently  published  by  Dr. 
Mondiere.* 

*  I/' Experience,  1839. 


SYMPTOMS.  197 

The  temperature  of  the  sweat  may  be  mild,  elevated  or  low ;  the 
latter  is  generally  an  unfavorable  omen. 

The  sweat  presents  numerous  varieties  in  relation  to  its  density 
and  color ;  it  is  sometimes  thick,  viscous  and  even  pitchy  as  in  the 
dying,  and  sometimes  thin  and  watery  ;  it  is  generally  colorless  ;  in 
some  cases,  it  imparts  to  the  linen  worn  a  yellow  tinge,  in  others, 
it  has  been  red  (sueurs  de  sang).  Cases  have  been  also  cited  by 
BorellL  Borrichius  and  Fourcroy,  in  which  the  sweat  was  of  a 
bluish  or  black  color.  The  sweat  differs  in  other  respects  ;  it  may 
be  slight,  moderate,  abundant,  transient,  continual  or  periodical ; 
it  may  be  solely  the  effect  of  disease,  or  be  excited  by  particular 
causes,  as  a  change  of  position,  cough,  warm  drinks,  &c.  ;  it  may 
relieve  or  enfeeble  the  patient,  sometimes  producing  fatal  results; 
it  is,  in  this  case,  called  colliquative  (sudores  colliquativi)  ;  this 
may  appear  at  the  commencement,  towards  the  middle  or  decline 
of  diseases,  or  continue  through  their  whole  course.  It  consti- 
tutes the  predominant  symptom  in  certain  affections  ;  as  in  the  dia- 
phoretic, pernicious,  intermittent  fever,  so  well  described  by  Torti, 
arid  to  which  he  came  near  perishing  a  victim.  Abundant  sweating 
is  one  of  the  principal  symptoms  in  the  sudor  picardicus,  and  it  was 
also  observed  in  that  terrible  epidemic,  the  sudor  anglwus  or  sweat- 
ing sickness,  which  in  the  middle  ages  ravaged  a  part  of  Europe. 

The  cutaneous  transpiration  may  be  diminished  or  suspended, 
as  is  often  observed  in  the  first  period  of  acute  diseases,  in  diabetes 
and  dropsy,  in  which  the  skin  is  habitually  dry. 

However  abundant  it  be,  the  transpiration  may  present  appre- 
ciable changes  in  its  odor,  a  circumstance  which  the  physician 
should  not  omit  to  notice.  The  odor  of  the  transpiration  is  gen- 
erally a  little  acid ;  sometimes,  fetid.  It  has  been  compared,  in 
rubeola  and  scarlatina,  to  that  of  mouldiness  ;  it  is  cadavoric  in 
some  adynamic  fevers. 

M.  Landre-Beauvais  and  Dance  *  have  noticed  in  cases  of  men- 
tal alienation  a  peculiar  odor  of  the  transpiration  with  which  the 
furniture  and  apartments  become  durably  impregnated,  whatever 
be  the  neatness  of  the  individual.  In  the  miliary  sweat,  the  odor 
exhaled  has  been  compared  by  some,  to  that  of  chlorine,  by  others, 
to  that  of  rotten  straw. 

The  odor  of  mice,  supposed  by  some  authors  to  be  one  of  the 
symptoms  which  frequently  accompany  fevers  of  bad  character 
and  cerebral  affections,  arises  both  from  the  flowing  of  the  urine 
into  the  bed  of  the  patient,  and  the  oil  cloth  placed  over  the  mat- 
trass,  the  emanations  of  which,  developed  by  the  heat  and  com- 
bined with  those  of  the  urine,  produce  this  peculiar  odor.  In  some 
cases,  the  odor  exhaled  by  the  patient  is  owing  to  his  food  and  the 
qualities  of  the  air  which  he  breathes.  In  persons  who  eat  garlic 
and  onions,  the  cutaneous  exhalation  is  charged  with  this  odor.  We 
have  had  at  the  hospital  a  groom,  who,  during  the  course  of  an 
inflammatory  bilious  fever,  continually  exhaled  a  strong  odor  of 

*  Manuel  de  Semeiotique. 

17* 


198  SYMPTOMS. 

the  stable.  We  satisfied  ourselves  that  all  his  clothing  was  re- 
moved, and  that  the  odor,  which  was  noticed  by  all  who  came 
near  him,  proceeded  from  the  patient  himself. 

In  the  course  of  acute  febrile  diseases  and  some  cases  of  hectic 
fever,  the  abundant  sweating  may  be  accompanied  by  numerous 
eruptions  of  vesicles,  particularly  apparent  upon  the  anterior  part 
of  the  trunk,  about  the  size  of  a  millet  seed  and  rilled  with  a  dia- 
phanous fluid,  generally  more  appreciable  to  the  touch  than  to  the 
eye,  breaking  under  the  ringer,  and  leaving  upon  the  pulp  a  sen- 
sation of  moisture  :  these  have  been  called  sudamina^  from  their 
resemblance  to  drops  of  sweat.  Of  all  acute  diseases  in  which 
this  phenomenon  is  observed,  typhoid  fever  is  that  in  which 
it  most  commonly  appears,  a  circumstance  not  without  value  in 
the  diagnosis  of  this  disease.  Abundant  sweating  is  not  necessary 
to  the  reproduction  of  sudamina,  and  it  is  not  uncommon  to  observe 
them  in  persons  who  have  been  free  from  sweating. 

2.  Disorders  of  the  mucous  exhalation  are  more  difficult  to  ap- 
preciate, because  the  membranes  from  which  they  take  place  are 
inaccessible  to  view.  The  alterations,  however,  which  they  pre- 
sent at  their  orifices  can  be  distinguished  by  the  eye,  and  the 
examination  of  the  excreted  matters,  may  throw  light  upon  the 
changes  effected  in  the  mucous  exhalation  in  deep-seated  organs, 
as  the  intestines,  bladder,  &c. 

In  health,  the  mucus,  the  consistence  and  quantity  of  which 
varies  in  the  different  parts  of  the  body  where  it  is  exhaled,  is 
furnished  in  such  a  proportion  as,  without  being  sufficiently  abun- 
dant to  escape,  to  prevent  the  adhesion  of  these  membranes,  facili- 
tate their  movements  and  the  passage  and  progression  of  the 
substances  taken  into  their  cavities.  Its  appearance  and  composi- 
tion varies  according  to  the  mucous  surface  from  which  it  is 
exhaled.  Thus  that  which  comes  from  the  neck  of  the  uterus  is 
ordinarily  clear,  transparent,  analogous  to  albumen,  without  odor, 
always  alkaline,  and,  when  viewed  with  the  microscope,  appearing 
homogeneous  and  free  from  globules  (Donne)  ;  the  vaginal  mucus, 
on  the  contrary,  is  thick,  creamy,  always  acid,  and  never  ropy.* 

In  disease,  the  mucous  exhalation  may  become  increased,  dimin- 
ished, suspended  and  variously  changed.  These  changes  rarely 
occur  simultaneously  in  all  parts  of  the  system.  Their  successive 
appearance  in  all  these  parts  is  more  frequently  observed,  as  in 
some  catarrhal  affections ;  they  are  most  frequently  partial.  In- 
crease of  the  mucus  exhaled,  is  noticed  in  the  second  period  of 
catarrh ;  its  diminution  is  sensible  at  the  commencement  of  this 
affection,  and  in  the  course  of  grave  fevers  ;  the  mucous  membrane 
of  the  mouth  and  nasal  fossae,  in  these  diseases,  is  often  very  dry. 

The  mucus  may  become  altered  in  its  qualities ;  its  odor  may 
be  nauseous,  spermatic,  and  sometimes  acid  or  fetid ;  its  color 
becomes  green  or  yellow  in  chronic  discharges ;  sometimes  red  in 
dysentery,  black  in  some  grave  fevers,  or  it  may  be  limpid  and 

*  DONNE,  Recherches  sur  les  divers  mucus. 


SYMPTOMS. 

resemble  the  white  of  the  egg,  as  in  certain  cases  of  bronchorrhoea ; 
in  other  cases,  it  may  be  white  and  opaque,  arid  it  is  then  often 
impossible  to  distinguish  it  from  pus.  Its  consistence  becomes 
diminished  in  the  pituatary  flux,  and  in  serous  diarrhoea,  and  is 
increased  in  chronic  catarrh ;  it  assumes,  in  some  cases,  a  flaky, 
membranous  or  tubular  form,  in  which  it  is  rejected  in  shreds. 
The  mucus  may  be  excreted  alone,  as  in  coryza,  angina,  and 
blennorrhagia ;  it  may  be  mixed  with  other  substances,  as  urine, 
in  cattarrh  of  the  bladder,  fa3cal  matters,  in  dysentery,  and  ali- 
mentary substances  in  vomiting.  From  whatever  surface  it  comes, 
it  may  be  mixed  with  blood  or  pus ;  in  the  latter  case,  the  purulent 
matters  form  in  the  opaque  mucus,  narrow  and  irregular  streaks 
still  more  opaque  :  this  is  daily  noticed  in  the  second  stage  of 
phthisis,  and  at  an  advanced  period  of  vesical  catarrh  occurring 
in  old  persons. 

Another  remarkable  alteration  presented  by  the  mucus  in  disease, 
is  the  contagious  property  it  acquires  in  blennorrhagia,  and,  ac- 
cording to  some  authors,  in  many  other  cattarrhal  affections;  by 
virtue  of  this  contagious  property,  it  may  cause,  in  a  healthy  per- 
son, the  development  of  an  affection  similar  to  that  by  which  it 
was  itself  produced. 

3.  In  health,  the  serous  exhalation  should  exist  in  such  propor- 
tion, that  the  membranes  and  areolae  which  it  is  destined  to  lubri- 
cate, should  be  always  moist,  without  ever  containing  fluid.     The 
disorders  of  this  exhalation  are  difficult  to  appreciate,  because  the 
organs  are  inaccessible  to  view,  and  there  is  no  excretion  whereby 
to  judge  of  the  changes  which  take  place. 

Does  the  diminution  or  suppressson  of  the  serous  exhalation 
ever  occur  during  life,  as  the  works  of  Marandcl  would  lead  us  to 
suppose?  This  question,  which  belongs  rather  to  pathological 
anatomy  than  symptomatology,  does  not  seem  to  us  yet  decided. 
We  only  know  that,  where  two  opposite  serous  surfaces  have  become 
adherent,  all  exhalation  is  necessarily  suspended,  or  so  modified  as 
no  longer  to  belong  to  this  kind  of  exhalation. 

The  increase  of  the  serous  exhalation  is  easy  to  distinguish 
when  it  occupies  the  cellular  tissue  (p.  76).  This  is  far  from 
being  the  case  when  there  is  an  accumulation  of  this  fluid  in  the 
serous  membranes;  it  may,  however,  give  rise  to  phenomena 
which  may  lead  us  to  suspect  it,  when  in  small  quantity,  and  to  be 
certain  of  its  existence,  when  in  abundance.  The  distension  of 
the  cavity  which  contains  the  fluid,  the  symptoms  arising  from 
compression  of  the  neighboring  organs,  and,  in  some  cases,  the 
fluctuation  and  the  changes  in  the  resonance  of  the  parts,  will 
generally  enable  us  to  distinguish  the  accumulation  of  serum. 

The  changes  in  the  color,  consistence  and  nature  of  the  exhaled 
fluid,  are  never  appreciable  during  life,  unless  there  be  an  acciden- 
tal opening  in  the  parietes  of  the  cavity  containing  it,  or  artificial 
issue  be  given  to  it.  This  change,  consequently,  belongs  to  patho- 
logical anatomy  rather  than  to  symptomatology. 

4.  The  exhalation  which  occurs  in  the  articular  cavities,  or  in 


200  SYMPTOMS. 

the  synovial  bursse,  furnishes  few  symptoms.  The  distension  of 
the  soft  parts,  obscure  fluctuation,  and  sometimes,  as  in  the  knee, 
the  shock  of  the  articular  surfaces,  under  the  pressure  of  the  hand, 
renders  the  accumulation  of  synovia  apparent.  In  some  cases 
also,  concretions  are  found  in  this  fluid,  which  are  entirely  free  and 
felt  at  intervals  in  different  parts  of  the  joint. 

5.  Increase  of  the  exhalation  in  the  eye  produces  hydropthalmia ; 
in  the  internal  ear,  it  leads  to  rupture  of  the  tympanum,  &c. 

6.  We  have  elsewhere  referred  to  the  exhalation  of  fat  in  its 
vesicles,  and  shall  not  here  again  recur  to  it.     We  shall  also  pass 
over  certain  exhalations  which  are  indicated  by  no  sensible  phe- 
nomenon, as  those  which  take  place  upon  the  internal  surface  of 
the  blood  vessels,  lymphatics,  &c. 

7.  To  these  different  kinds  of  exhalation,  that  may  be  added 
which  furnishes  the  digestive  tube  with  the  gases  necessary  to  its 
functions,  and  which  presents,  in  disease,  modifications  more  or  less 
remarkable,  owing  to  which  the  abdomen  becomes  sometimes  very 
voluminous  and  resonant,   and  sometimes  flattened,  and  almost 
entirely  dull  on  percussion.     These  variations  in  the  volume  and 
resonance  of  the  abdomen,  frequently,  rather  depend  upon  some 
obstacle  to  the  circulation  of  the  gases  in  these  viscera,  than  to 
their  too  abundant  secretion ;  but  sometimes,  particularly  in  hys- 
terical females,  the  sudden  changes  which  the  abdomen  presents, 
without  the  occurrence  of  any  gaseous    emission,  can  only  be 
accounted  for  by  supposing  alternations  of  exhalation  and  absorp- 
tion of  these  gases. 

8.  Lastly,  the  sanguineous  exhalations,  which,  in  health,  period- 
ically make  their  appearance  and  concur  in  maintaining  the  general 
equilibrium  of  the  functions,  may,  in  disease,  be  increased,  dimin- 
ished, suppressed,  or  only  diverted.     The  menstrual  exhalation 
frequently  presents  these  various  phenomena  in  the  diseases  of 
females,  and  analogous  disorders  have  been  many  times  observed 
in  men  accustomed  to  the  haemorrhoidal  flux  or  epistaxis,  &c. 

But  if  there  are  some  normal  hsemorrhages  which  are  connected 
with  health,  and  form  a  part  of  its  attributes,  there  are  many 
more  which  only  appear  under  the  influence  of  disease  and,  in 
some  cases,  alone  suffice  to  constitute  it. 

B.     Morbid  Exhalations. 

At  the  head  of  morbid  exhalations,  may  be  mentioned  those  of 
the  blood,  or  hemorrhages,*  and  of  pus,  or pyogenia.-\ 

1.  Haemorrhages  consist  in  the  escape  of  blood  from  the  vessels 
destined  to  contain  it :  this  flow  is  sometimes  owing  to  the  action 
of  a  wounding  instrument,  which,  by  dividing  the  vessels  in  which 
the  blood  circulates,  furnishes  the  natural  explanation  of  the  acci- 
dent produced.  But,  in  many  cases,  the  flow  of  the  blood  from 

*  -Atuct,  blood  5  PSW,  I  run. 

t  TLvov,  pus;  ytVowui,  I  am  generated. 


SYMPTOMS. 

these  canals,  occurs  independently  of  any  external  cause ;  the 
haemorrhage  takes  place,  as  it  were,  spontaneously,  and  is  hence 
called  spontaneous,  in  opposition  to  the  preceding,  which  is  called 
traumatic.  Among  the  haemorrhages,  called  spontaneous,  some  are 
connected  with  a  material  lesion  of  the  part,  from  which  the  blood 
proceeds,  as  tubercles,  cancer,  &c ;  these  are  termed  symptomatic. 
Others,  epistaxis,  for  example,  occur,  without  the  existence  of  any 
lesion  discoverable  during  life  or  by  examination  after  death,  to 
account  for  such  a  phenomenon  :  these  have  been  called  essential, 
as,  being  symptomatic  of  no  appreciable  affection,  they  themselves, 
in  the  present  state  of  the  science,  represent  the  disease.  These 
essential  haemorrhages  are  by  no  means  the  most  common  ;  if  we 
except  epistaxis  and  the  haemorrhoridal  flux,  which  often  relieve 
the  wants  of  the  constitution,  and  which,  like  the  menstrual  flow, 
contribute  to  health,  they  are,  as  we  shall  see  in  the  chapter  on 
diagnosis,  in  most  cases,  symptomatic ;  they  are  sometimes  owing 
to  a  lesion  of  the  organ  from  which  the  blood  flows,  and  of  which 
they  constitute  the  first  sign ;  and  sometimes  to  a  general  affection 
of  the  economy,  the  blood,  in  these  cases,  often  flowing  from  dif- 
ferent parts,  as  in  scurvy  and  some  pestilential  diseases.  Spon- 
taneous haemorrhages  generally  occur  from  the  mucous  membranes, 
rarely  from  old  cicatrices  or  any  other  point  of  the  cutaneous 
surface ;  they  sometimes  appear  in  the  cellular  tissue,  where  they 
form  spots  and  ecchymoses,  to  which  we  have  referred  above.  The 
blood  may  be  also  exhaled  into  the  serous  and  synovial  mem- 
branes, into  the  parenchyma  of  the  viscera,  muscles,  &c. ;  but,  in 
such  cases,  the  haemorrhage  is  often  manifested  by  no  certain  sign. 
The  blood  which  flows  from  the  body,  presents  varieties  in  its 
color,  which  may  be  florid  red  or  livid,  in  its  consistence,  which 
may  be  soft  or  firm,  in  its  quantity,  which  may  vary  from  a  few 
drops  to  several  pounds,  and  in  the  substances  with  which  it  may 
be  mixed.  Haemorrhages  differ  also  in  respect  to  the  period  of  the 
disease  in  which  they  occur,  and  the  influence  they  exert  upon  its 
progress  and  termination :  they  have  hence  been  distinguished 
into  those  that  are  favorable,  prejudicial,  or  indifferent. 

2.  Pyogenia.  The  opinions  of  physicians  upon  the  formation 
of  pus,  have  been  very  various :  some,  have  pretended,  with 
Dehaen,  that  it  is  formed  in  the  arterial  system,  to  be  exhaled  in 
the  inflamed  part ;  others,  that  it  can  only  be  produced  where  it  is 
found  to  exist.  Among  the  latter,  some  have  regarded  pus  as 
proceeding  from  the  broken  down  parts  where  the  suppuration  is 
taking  place :  others  have  considered  it  the  result  of  a  chemical 
combination  between  the  various  fluids  of  the  affected  part,  and  par- 
ticularly between  the  lymph  and  fat.  These  two  opinions,  the  first 
of  which  has  been  for  a  long  time  favored  in  the  schools,  and  the 
second  of  which  has  but  few  followers,  are  now  generally  aban- 
doned, and  pus  is  now  considered  as  the  result  of  a  morbid 
exhalation  from  the  same  organs  which  produce  the  natural  exha- 
lations. 

A  very  remarkable  phenomenon  in  the  exhalation  of  pus,  is, 


202  SYMPTOMS. 

that  it  does  not  present  the  appearance  and  consistence  peculiar  to 
it,  till  after  it  has  remained  for  a  certain  length  of  time  upon  the 
organ  which  furnishes  it.  Van  Swieten  remarked  that  when  the 
fluid  furnished  by  a  wound  was  hourly  removed  with  a  sponge, 
the  fluid  thus  obtained  was  not  purulent,  but  a  thin  and  turbid 
serum. 

All  the  tissues  are  not  equally  disposed  to  the  formation  of  pus  ; 
but  there  is  none,  with,  perhaps,  the  exception  of  the  tendons, 
cartilages  and  aponeurosis,  in  which  inflammation  may  not  pro- 
duce suppuration.  Inflammation  does  not  always  produce  pus,  but 
it  is  generally  supposed  that  the  latter  is  never  formed  unless  there 
have  been  previous  inflammation,  either  in  the  part  where  the  pus 
exists,  or  at  a  greater  or  less  distance  from  it;  in  the  latter  case, 
the  pus  may  have  reached  the  point  it  occupies  in  obedience  to  the 
laws  of  gravity  (abscess  by  congestion),  or  have  been  displaced  by 
the  exhalent  vessels  after  having  been  absorbed  in  a  more  or  less 
remote  part  of  the  economy  (metastic  abscesses).  See  METASTASIS. 

The  displacement  of  the  pus  in  abscesses  by  congestion,  is  a 
phenomenon  which  has  long  been  known,  and  upon  the  production 
of  which  there  has  been  little  diversity  of  opinion.  Pus  formed 
slowly  at  some  elevated  part  of  the  body,  without  being  circum- 
scribed by  previous  acute  inflammation,  may  find  its  way  down 
between  the  meshes  of  the  cellular  tissue,  and  collect  at  the  lowest 
point,  in  the  loins,  for  example,  or  in  the  superior  part  of  the 
thighs,  and  form  a  fluctuating  tumor  at  some  distance  from  the 
place  where  it  was  produced.  In  regard  to  metastatic  abscesses, 
they  have  been  of  late  particularly  studied,  but  their  history  still 
presents  some  obscure  points.  They  have  been  frequently  observed 
in  variola,  in  the  period  of  desquamation :  they  appear,  in  these 
cases,  as  brownish,  fluctuating  tumors,  very  tender  on  pressure, 
being  formed  and  discharging  themselves  with  great  rapidity,  in  a 
few  days  or  hours,  and  from  which  flows  a  reddish  or  sanious 
pus :  this  fluid,  which  is  doubtless  absorbed  from  the  variolic 
pustules,  finds  its  way  to  the  skin,  being  very  rarely  deposited  in 
the  internal  parts.  It  is  far  otherwise  with  the  abscesses  which 
follow  wounds,  surgical  operations,  parturition,  between  which  and 
the  two  first  conditions  there  exists  some  analogy,  and  phlebitis 
produced  by  venesection.  In  these  cases,  rigors  and  ataxic  symp- 
toms supervene,  followed  by  the  appearance  of  indolent  fluctuating 
tumors  in  different  parts  of  the  body,  and  sometimes  in  the  sub- 
stance of  the  muscles,  varying  in  size  from  that  of  a  nut  to  that 
of  a  pullet's  egg.  In  some  cases,  one  or  more  articulations  present 
swelling  and  fluctuation,  with  or  without  pain.  Examination 
after  death,  reveals  the  existence  of  pus  at  all  these  points,  and 
often  numerous  internal  abscesses,  scattered  through  those  viscera 
which  are  the  most  vascular,  as  the  lungs,  liver  and  spleen  ;  more 
rarely  the  brain  and  kidneys ;  and,  in  many  cases,  there  are  evi- 
dent traces  of  inflammation  in  some  part  of  the  venous  system. 
This  assemblage  of  phenomena,  has  led  all  physicians  to  regard 
these  abscesses  as  produced  by  the  passage  of  pus  into  the  blood, 


SYMPTOMS.  203 

whether  the  pus  formed  in  the  veins  be  thus  carried  throughout 
the  circulatory  system,  or  be  introduced  into  it  by  means  of  lym- 
phatic or  venous  absorption.  But  in  the  attempts  to  explain  the 
formation  of  these  abscesses,  there  has  not  been  the  same  unanim- 
ity of  opinion  ;  some  have  supposed  them  to  be  merely  depositions 
of  pus  which  has  been  absorbed  ;  others  have  considered  that  the 
blood,  altered  by  its  mixture  with  pus,  becomes,  in  various  parts 
of  the  economy,  the  material  cause  of  a  suppurative  inflammation. 
Neither  of  these  opinions  is  wholly  admissible ;  the  former,  be- 
cause these  abscesses  are  formed  not  only  in  open  cavities,  as  the 
meshes  of  the  cellular  tissue  and  synovial  membranes,  but  in  the 
parenchyma  of  the  lungs,  liver,  spleen,  brain,  kidneys  and  mus- 
cles, in  which  a  cavity  cannot  be  formed  except  by  means  of  an 
inflammatory  process ;  it  may  be  added  that  the  abundance  of  pus 
found  in  metastatic  abscesses,  is  often  disproportionate  to  the  extent 
of  surface  where  the  pus  was  first  formed,  and  finally,  that  the 
pus  deposited  in  an  organ,  itself  becomes  an  agent  of  suppuration; 
that  the  pus,  as  has  been  said,  produces  pus.  In  regard  to  the 
second  opinion,  the  alteration  of  the  blood  by  pus,  it  does  not 
account  for  the  rapidity  with  which  these  collections  form  in  the 
subcutaneous  cellular  tissue,  often  without  the  existence  of  pain. 
It  might  also  be  asked,  how  a  general  cause  can  produce  circum- 
scribed, though  multiple,  results.  It  may  then  be  admitted,  from 
observation,  that  the  pus  carried  into  the  circulation,  is  deposited 
in  various  quantities,  in  different  parts  of  the  economy,  so  as  indi- 
rectly to.  form,  in  one  part,  an  abscess,  and  in  another,  become  the 
material  cause  of  a  suppurative  inflammation.  In  regard  to  the 
causes,  by  virtue  of  which,  pus  that  has  been  absorbed,  is  depos- 
ited in  some  parts  rather  than  others,  and  in  various  quantities, 
they  are  in  the  present  state  of  the  science  entirely  unknown  :  the 
artificial  irritations  established  by  the  physician  upon  the  skin,  by 
means  of  topical  rubefaciants  or  vesicants,  are  not  here  called 
purulent  collections,  and  seem  to  have  no  influence  upon  the 
unequal  and  inexplicable  distribution  of  this  deleterious  fluid  in 
the  various  parts  of  the  body. 

The  softening  of  tubercles  is  a  phenomenon  which  appears  op- 
posed to  the  opinion  above  expressed,  viz.,  that  the  presence  of  pus 
is  a  sign  of  previous  inflammation.  A  body,  to  all  appearance 
unorganized,  is  formed  in  the  tissue  of  the  lungs  or  some  other 
organ  ;  it  acquires  a  certain  size,  and  is  then  found  to  present  an 
opaque  color,  moderate  hardness  and  great  friability.  At  the 
end  of  a  certain  time  it  becomes  softened  sometimes  throughout  its 
whole  extent,  sometimes  at  its  centre,  and  is  converted  into  a  mat- 
ter analogous  to  the  pus  exhaled  by  an  inflamed  organ  ;  but  si- 
multaneously with  the  occurrence  of  this  change,  redness,  swelling 
and  heat  supervene  in  the  surrounding  parts,  as  in  the  case  of  sub- 
cutaneous tubercles  ;  and  hence  it  is  natural  to  suppose  that  the 
inflammation  of  the  neighboring  parts  is  not  foreign  to  the  trans- 
formation of  the  tuberculous  matter  into  pus. 

The   pus   exhaled  upon   the   surface   of  the  skin,   or  external 


204  SYMPTOMS. 

wounds,  escapes  freely.  That  formed  internally  sometimes  extends 
throughout  the  tissue  of  an  organ,  as  is  observed  in  the  lungs,  and 
sometimes  forms  one  or  more  collections  termed  abscesses.  The 
pus  collected  into  an  abscess  ordinarily  finds  its  way  towards  the 
integuments  or  the  canals  through  which  it  may  be  discharged 
from  the  body,  by  the  gradual  absorption  of  the  intervening  parts. 
Pus  which  extends  throughout  the  tissue  of  an  organ  cannot  be 
evacuated  in  this  way,  and  absorption  is  the  only  means  by  which 
it  can  be  removed.  This  absorption  is  manifest  in  some  subcu- 
taneous abscesses,  particularly  in  buboes;  such  inflammatory 
tumors  after  being  soft  and  fluctuating,  in  a  few  days,  and  even  a 
few  hours,  may  gradually  flatten,  and  the  fluctuation  disappear. 

Pus,  considered  in  itself,  presents  varieties  relative  to  its  physical 
and  chemical  properties,  and  its  action  upon  the  animal  economy. 

Its  quantity  is  relative  to  the  extent  of  the  suppurating  surface, 
the  period  of  the  disease  and  many  other  circumstances.  It  may 
be  diminished  by  errors  in  diet,  violent  mental  emotions,  a  febrile 
recrudescence  which  should  always  lead  us  to  fear  a  complica- 
tion or  purulent  absorption,  or  any  other  supervening  evacua- 
tion. Hatter  observed  that  the  exhalation  of  this  fluid  was  gen- 
erally more  abundant  in  the  night  than  during  the  day. 

The  color  of  pus  is  ordinarily  yellowish  white,  or  greenish ; 
it  is  sometimes  reddish  or  livid;  it  has  been  noticed  to  be  bright 
yellow  in  persons  affected  with  jaundice.  Its  color  is  sometimes 
uniform  throughout,  sometimes  diversified;  in  some  cases  it  is 
thick,  homogeneous,  and  its  globules,  when  examined  with  the 
microscope,  very  abundant ;  this  is  called  laudable  or  healthy  pus ; 
it  is  observed  in  cases  of  healthy  inflammation  running  a  rapid 
course,  and  occurring  in  persons  of  good  constitution.  In  other 
cases,  it  is  clear  and  mixed  with  opaque  flocculi ;  it  sometimes  re- 
sembles badly  clarified  whey,  as  is  observed  in  chronic  abscesses 
which  occur  in  scrofulous  persons  and  those  of  bad  constitution. 
Sometimes  serous  or  sanious  pus  becomes  of  a  brownish  color  by 
the  contact  of  the  air ;  it  blackens  silver  and  lead  instruments  with 
which  it  comes  in  contact;  this  has  been  attributed  to  the  sulphur- 
retted  hydrogen  gas  contained  in  it.  Some  abscesses  of  the  liver 
furnish  a  thick,  reddish  matter,  resembling  the  lees  of  wine, 
which  deposits,  on  standing,  portions  of  the  substance  of  the  liver. 
Surgeons,  and  Boyer  in  particular,  did  not  admit  that  any  other 
than  that  presenting  these  conditions,  proceeds  from  the  liver,  but 
it  is  now  proved  that  a  phlegmonous  pus  has  been  found  to  exist 
in  this  viscus,  several  examples  of  which  have  been  published  by 
M.  Louis,  as  occurring  at  La  Charite  and  observed  by  us  together. 

The  odor  of  pus  is  ordinarily  nauseous,  sometimes  character- 
ized by  a  penetrating,  nauseous  or  insupportable  fetor.  It  has  been 
long  observed  by  surgeons  that  pus  contained  in  an  abscess  of  the 
abdominal  parietes,  or  at  the  margin  of  the  anus,  often  exhales  the 
most  fetid  odor,  analogous  to  that  of  the  faecal  matters,  so  as  to 
lead  to  the  suspicion  of  a  communication  between  the  abscess 
and  intestines.  Abscesses  of  the  mouth  and  pharynx  also  yield  a 


SYMPTOMS.  205 

very  fetid  pus.  Every  one  is  familiar  with  the  repulsive  odor  that 
pus  acquires  in  ahscesses  of  the  labia  majora  in  females,  and  in 
urinal  abscesses  of  both  sexes.  This  fetor  is  not  generally  ap- 
parent at  the  time  the  abscess  is  opened,  except  in  those  cases  in 
which  it  exists  at  the  surface  of  the  skin,  or  in  the  neighborhood 
of  organs  which  contain  air.  It  may  acquire  this  odor  after  the 
abscess  is  opened,  if  air  be  admitted  into  the  cavity.  The  taste 
of  pus,  according  to  Schcvilgue,  is  nauseous  and  sometimes  acrid  : 
its  specific  gravity  is  greater  than  that  of  distilled  water.  The 
same  causes  which  influence  its  quantity  ordinarily  modify  its 
other  physical  qualities,  and  particularly  its  consistence  and  color. 
The  chemical  properties  of  pus,  being  of  no  practical  value,  we 
shall  not  here  consider. 

The  action  of  pus  upon  the  economy  deserves  particular  atten- 
tion ;  this  varies  according  to  the  tissues.  Upon  the  skin,  pus 
causes  only  redness  and  excoriation  ;  in  the  cellular  tissue,  through 
which  it  flows,  it  excites  the  formation  of  new  pus ;  in  the  vicinity 
of  bones,  it  wears  them  away  by  exciting  in  their  tissue  interstitial 
absorption.  If  it  exist  in  circumscribed  abscess,  and  come  in  con- 
tact with  the  air,  it  soon  acquires  a  strong  odor,  loses  its  homoge- 
neousness,  and  produces  general  functional  disturbance  and  death. 
The  same  phenomenon  occurs  whenever  the  pus,  without  being 
altered,  is  accumulated  in  one  of  the  splanchnic  cavities,  or  one  of 
the  viscera  important  to  life.  We  have  above  referred  to  the  me- 
tastatic  phenomena  which  may  result  from  its  absorption.  Finally, 
this  fluid  may,  in  some  diseases,  become  the  vehicle  of  contagion, 
as  is  observed  in  variola,  syphilis  and  glanders. 

The  distinction  between  mucus  and  pus  is  one  of  the  points  which 
most  occupied  the  attention  of  physicians  of  the  last  century. 
They  supposed  that  pus  was  constantly  the  result  of  a  solution  of 
continuity,  and  never  owing  to  simple  exhalation ;  in  order  to  re- 
tain the  name  of  pus  for  certain  fluids  which  presented  all  its 
characteristics,  they  were  also  obliged  to  suppose  ulcerations  where 
they  did  not  exist ;  they  supposed  their  existence  in  the  urethra 
and  uterus  when  affected  with  catarrh.  The  chemical  experi- 
ments, which  have  been  made,  in  order  to  determine  the  true 
characteristics  of  pus,  have  terminated  in  nothing  satisfactory. 
The  results  of  microscopical  researches,  have  been  equally  unsuc- 
cessful. It  was  thought  for  a  long  time  that  when  globules,  simi- 
lar to  those  observed  in  the  blood,  were  noticed  in  the  secretion  of 
a  mucous  membrane,  they  indicated  the  presence  of  pus.  But  it 
is  now  proved  that  mucus  varies  much  in  its  physical  and  chemi- 
cal composition,  and  that  it  often  contains  globules,  which,  in 
their  form  and  volume,  resemble  those  of  pus.  Chemical  reagents 
and  the  miscroscope  are  useless  when  the  appearances  presented 
by  pus  and  mucus  are  distinct;  they  are  also  insufficient,  when 
these  two  fluids  resemble  each  other. 

3.  There  are  still  other  essentially  morbid  exhalations  which 
need  only  to  be  enumerated  ;  such  are  those  occurring  between  the 
reticular  tissue  of  the  skin  and  epidermis,  in  pemphigus  and  all 
18 


206  SYMPTOMS. 

the  vesicular  and  pustular  eruptions.  These  fluids,  in  coagulating 
and  hardening  by  exposure  to  the  air,  form,  upon  the  surface  of 
the  skin,  peculiar  concretions,  to  which  the  term  crusts  or  scabs 
has  been  applied.  Their  study  is  not  without  importance  in  cutane- 
ous pathology ;  for  by  considering  their  form,  surface,  degree  of 
prominence  or  depression,  color,  hardness,  degree  of  adherence, 
etc.,  we  are  enabled  to  determine  the  kind  of  cutaneous  disease 
without  having  seen  it  in  its  elementary  form.  It  is  thus  that 
porrigo  favosa  is  distinguished,  its  crusts  being  yellowish  and  pre- 
senting a  cuplike  depression  ;  these  crusts  are  yellow,  thick  and  fria- 
ble in  impetigo;  they  are  very  adherent,  thick,  blackish  and 
elevated  in  the  centre,  in  ecthyma ;  while  in  vesicular  and  bulbous 
affections,  they  are  thin,  easily  detached,  and  of  a  yellowish  or 
brownish  color. 

The  skin  may  be  also  the  seat  of  another  morbid  exhalation,  to 
which  the  term  squamous  has  been  applied,  and  which  is  charac- 
terized by  the  formation,  upon  the  diseased  surface,  of  an  inorganic, 
lamellar  substance  of  a  grayish  white  color,  dry,  friable,  more  or 
less  thick  and  adherent,  and  which  is  regarded  as  a  morbid  secre- 
tion of  the  epidermis.  Scales  are  observed  in  lepra,  psoriasis, 
pityriasis  and  icthyosis. 

C.    Artificial  Exhalations. 

Artificial  exhalations  are,  in  relation  to  symptomatology,  of  less 
importance  than  all  others.  It  may,  however,  be  well  for  the  phy- 
sician to  know  the  quantity  and  quality  of  the  pus  furnished  by 
cauterization,  vesication,  moxas  and  setons ;  the  aspect  of  the  ex- 
halent  surface  also  deserves  special  attention. 

In  diseases,  in  which  the  strength  is  maintained,  the  pus  of 
artificial  ulcers  is  in  a  certain  quantity,  of  a  proper  consistence, 
homogeneous,  and  its  odor  is  not  repulsive ;  the  surface  from  which 
it  proceeds  is  of  a  rosy  or  red  color,  and  acutely  sensitive  without 
being  morbidly  so.  In  diseases  which  tend  to  a  fatal  termination, 
the  pus  is  almost  always  serous  or  of  unequal  consistence,  it  is 
sometimes  mixed  with  blood  and  often  emits  xa  very  fetid  odor; 
the  exhalent  surface  is  pale  or  livid,  sometimes  ecchymozed  or 
black ;  it  is  sometimes  insensible,  and  sometimes  the  least  touch 
excites  in  it  severe  pain.  When  artificial  ulcers  exist  before  the 
disease,  it  often  happens  that  they  become  dry  a  few  days  previous 
to  its  development,  or  the  matter  exhaled  may  present  remarkable 
changes. 

$  II.    Secretions  properly  so  catted. 

In  health,  the  secretions  concur,  together  with  the  exhalations,  in 
maintaining  the  general  equilibrium  ;  the  first  increasing  when  the 
second  diminish,  and  vice  versa.  In  disease,  this  order,  sometimes 
preserved,  is  often  interrupted,  and  cases  occur  where  both  are 
simultaneously  increased  or  diminished.  In  the  cases  of  hectic 


SYMPTOMS.  207 

fever  that  fell  under  the  observation  of  Cotugno  at  Naples,  there 
were,  at  the  same  time,  continual  perspiration,  laxity  of  the  bowels, 
and  a  copious  flow  of  urine.  In  the  first  and  second  stage  of 
many  acute  diseases,  the  secretions  and  exhalations  are  simultane- 
ously suspended  ;  the  skin  is  dry,  the  abdomen  contracted,  and  the 
urine  is  excreted  in  small  quantities. 

Independently,  however,  of  this  general  disturbance,  the  particu- 
lar secretions  are  subject  to  changes,  which  we  proceed  to  enume- 
rate. 

1.  The  tears  in  health  are  secreted  in  such  proportion,   that 
while  the  eyes  and  eyelids  are  constantly  moistened,  none  of  the 
fluid  flows  out  over  the  cheeks.     Under  certain  circumstances,  as, 
the  existence  of  vivid  mental  emotions,  the  exposure  of  the  face  to 
cold  winds,  etc.,  the  tears  are  secreted  in  greater  abundance,  filling 
the  eyes,  and  even  escaping  upon  the  face.     In  disease,  the  secre- 
tion of  the  tears  is  seldom  diminished ;  it  is  increased,  in  the  first 
stage  of  eruptive  fevers,  particularly  rubeola,  in  the  decline  of  the 
paroxysm  in  hysteria,  and  in  some  forms  of  monomania.     The 
tears  are  also  more  abundant  in  many  diseases  of  the  eyes,  and 
particularly  ophthalmia.     During  the  existence  of  tic  douleureux 
in  the  ophthalmic  branch  of  the  fifth  pair,  the  secretion  of  the 
tears  is  increased,  and  they  often  produce  a  sensation  of  warmth 
or  burning  in  the  parts  with  which  they  come  in  contact.*     In 
some  cases,  the  tears  appears  to  be  altered  in  their  nature,  becom- 
ing more  acrid,  to    judge  from  the   effect  which    they  produce 
upon  the  skin  of  the  face,  over  which  their  passage  is  indicated  by 
redness  and  excoriation. 

The  fluid  secreted  by  the  follicles  of  Meibomius  sometimes 
forms  a  kind  of  gummy  concretion,  (chassie),  which  has  the  effect 
of  producing  adhesion  of  the  eyelashes  and  consequently  the  free 
edges  of  the  eyelids.  This  alteration  of  the  secretion  occurs  in 
most  cases  of  ophthalmia,  particularly  the  ophthalmia  of  children, 
and  in  the  inflammation  of  the  eyelids  such  as  results  from  an 
extension  of  erysipelas  of  the  face.  Lastly,  the  eyes  often  become 
thus  affected  at  the  close  of  acute  diseases  which  terminate  unfa- 
vorably. v 

2.  The  secretion  of  the  saliva  in   health  is  abundant  during 
meals,  but  diminishes,  and  its  excretion  almost  entirely  ceases,  in 
the  intervals,  unless  excited  by  the  imagination,  or  by  mastication, 
etc.     In  disease,  the  secretion  of  the  saliva  is  sometimes  increased 
to  a  considerable  degree,  either  in  consequence  of  the  disease  itself, 
or  the  remedies  employed  for  its  cure,  as  the  different  mercurial 
preparations.     This    increase  is  termed    salivation  or   ptyalism^ 
(salivatio,  ptyalismus),  and  is  generally  accompanied  by  swelling 
of  the  gums,  cheeks,  tongue,  and  more  rarely,  the  parotid  region. 

*  The  flow  of  tears  over  the  cheeks  does  not  always  indicate  an  increased  se- 
cretion. The  inertia  of  the  puncta  and  lachrymal  canals,  the  eversion  of  the  lower 
eyelid,  the  obstruction  of  the  lychrymal  sac  or  nasal  canal,  and  certain  diseases  of 
the  eyelids,  may  also  produce  epiphora. 

t  IZrvaiLioubg,  from  TTTVCU,  I  spit. 


208  SYMPTOMS. 

Salivation  has  been  attributed  to  an  increased  secretion  in  the  sali- 
vary glands  (parotid,  submaxillary,  sublingual)  produced  by  the 
elective  action  of  mercury  upon  these  glands ;  but  more  exact  ob- 
servation having  proved  the  existence  of  considerable  swelling  of 
the  mucous  membrane  of  the  mouth,  unaccompanied  often  by  any 
swelling  of  the  salivary  glands,  we  should  refer  the  increased 
secretion  of  which  the  mouth  is  the  seat,  chiefly  to  its  lining 
membrane,  and  the  numerous  follicles  with  which  its  surface 
is  covered,  according  but  a  secondary  influence,  in  the  phenomenon 
of  salivation,  to  the  salivary  glands,  properly  so  called.  The  sali- 
vary secretion  is  also  increased  in  inflammations  of  the  throat,  in 
cases  of  aptha3,  ulcerations  and  glossitis,  and  during  dentition 
which,  according  to  most  authors,  it  facilitates.  Sydenham  laid 
great  stress  on  ptyalism  occurring  in  variola  of  adults,  commencing 
generally  with  the  eruption  and  terminating  towards  the  twelfth 
day.  Its  termination  before  this  period,  he  considered  an  unfavor- 
able omen.  If  we  consider,  however,  that  this  salivation  is  often 
owing  to  an  eruption  of  variolic  pustules  in  the  mouth,  we  shall 
attach  less  importance  to  the  phenomenon  pointed  out  by  Syden- 
ham. 

The  secretion  of  saliva  is  diminished  in  most  acute  diseases,  in 
which  the  mouth  is  constantly  dry.  It  appears  to  undergo  a 
change  in  many  cases  of  neurosis,  in  which  it  becomes  acrid  and 
burning;  in  some  diseases  of  the  bladder,  in  which  it  has  a  urinous 
taste ;  and  in  hydrophobia,  in  which  it  seems  to  acquire  contagious 
properties.  Its  excretion  becomes  difficult  or  impossible  in  cases 
of  obstruction  or  obliteration  of  the  excretory  ducts.  It  may 
escape  externally  in  cases  of  wounds  or  fistula  of  the  ducts  or 
glands  themselves. 

The  principal  chemical  modification  which  the  saliva  undergoes 
is  the  passage  from  an  alkaline  to  an  acid  state.  This  acidity  has 
been  observed  by  M.  Donne,  to  acccompany,  most  generally,  an 
irritated  or  inflammatory  state  of  the  stomach,  either  primary  or 
secondary,  and  he  thought  might  serve  to  establish  the  diagnosis 
of  some  gastric  affections.  But  the  researches  of  other  physicians 
on  this  point  have  not  confirmed  the  results  published  by  M.  Donne, 
and  renewed  examination  will  be  necessary  to  remove  this  uncer- 
tainty. The  permanent  acidity  of  the  saliva  seems,  as  some  au- 
thors have  remarked,  to  exert  an  influence  on  the  development  of 
dental  caries.  Lastly,  the  acidity  of  the  saliva  is  one  of  the  most 
common  causes  of  acidity  of  the  breath,  which  has  been  before 
considered  (page  137),  and  which  deserves  the  particular  attention 
of  the  physician. 

3.  The  secretion  and  excretion  after  bile,  occur  in  health  without 
any  apparent  phenomenon,  the  situation  of  the  biliary  organs  not 
permitting  us  to  observe  the  changes  they  may  present.  It  is 
nearly  the  same  in  cases  of  disease ;  necropsies  frequently  bring  to 
light  lesions  in  this  fluid  itself,  and  in  the  disposition  of  its  excre- 
tory ducts,  which  had  not  been  suspected  in  life.  Even  at  the 
present  day,  we  have  but  a  very  imperfect  knowledge  of  the  dif- 


SYMPTOMS.  209 

ferent  modifications  which  health  and  disease  may  effect  in  the 
composition  of  the  bile.  In  fact,  if  we  consult  all  the  works  on 
pathology  published  since  the  time  of  Galen,  and  particularly  dur- 
ing the  last  two  or  three  centuries,  we  shall  find  that  the  physi- 
cians of  this  long  period,  have  described  a  multitude  of  changes  in 
the  bile,  by  the  aid  of  which  they  have  explained  the  nature  of 
many  diseases  and  the  forms  under  which  they  are  presented;  but 
this  doctrine,  connected  with  the  humoral  ideas  then  entertained, 
was  supported  by  no  positive  proof. 

The  bile  in  its  normal  state,  is  liquid,  of  a  yellow  or  greenish  color, 
viscous,  ropy,  bitter  and  slightly  alkaline.  It  may  present  different 
degrees  of  consistence  or  color,  without  our  being  able  to  determine 
how  far  these  modifications  are  consistent  with  health.  The  bile 
is  often  changed,  either  in  quantity  or  quality,  in  many  diseases 
of  which  the  biliary  apparatus  is  not  the  principal  seat ;  while  in 
many  deep-seated,  though  partial  affections  of  the  liver,  as  cancer 
and  abscess,  the  bile  undergoes  apparently  no  remarkable  change, 
this  organ  preserving  its  normal  texture  in  those  portions  of  its 
parenchyma  which  lie  between  the  cancerous  parts,  or  the  puru- 
lent collections. 

M.  Louis  has  satisfactorily  established  that  alterations  in  the 
bile  and  the  gall-bladder  are  much  more  frequent  in  the  course  of 
the  typhoid  affection,  than  in  the  other  acute  diseases ;  and  that  of 
all  the  chronic  affections,  pulmonary  phthisis  is  that  in  which  the 
bile  most  frequently  undergoes  change,  in  such  cases,  closely  re- 
sembling treacle.  M.  Andral  has  noticed  in  the  same  affection, 
that  the  bile  is  sometimes  replaced  by  a  fatty  fluid.  In  atrophy  of 
the  liver,  and  especially  in  cyrrhosis,  the  bile  generally  exists  in 
small  quantity  and  is  sometimes  almost  colorless  and  albuminous. 
M.  Hermann,  of  Moscow,  is  confident  that  in  Asiatic  cholera  the 
bile  contains  a  very  large  proportion  of  resinous  matter.  This 
fluid  may  acquire  irritating  and  even  poisonous  properties,  as  has 
heen  proved  by  the  experiments  of  Deidier  *  on  the  bile  of  persons 
affected  with  the  plague  at  Marseilles  in  1720,  and  by  Vicq 
d'Azir,  f  in  an  epizooty  which  he  observed  in  1778.  We  are  still 
entirely  ignorant  whether  an  alteration  in  the  bile  is  connected  in 
any  way  with  those  diseases  of  warm  countries,  described  under 
the  name  of  bilious  fevers,  or  with  certain  sporadic  choleras. 
English  physicians  are  of  opinion  that  a  great  number  of  the  de- 
rangements of  the  digestive  organs,  are  connected  with  some 
change  in  the  composition  of  the  bile;  but  nothing  is  with  cer- 
tainty known  upon  this  subject. 

A  greater  part  of  the  alterations  in  the  bile  of  which  we  have 
just  spoken,  have  only  been  verified  after  death  by  examination  of 
the  fluid  collected  in  the  gall-bladder;  they  consequently  belong  to 
pathological  anatomy,  rather  than  to  symptomatology.  Never- 
theless, we  have  thought  it  best  to  enumerate  in  this  connection 

*  Exper.  sur  la  Bile,  Zurich,  1722. 

|  Mo  yens  Cur.  Contre  les  Malad.,  Peslil,  p   94. 

18* 


210  SYMPTOMS. 

the  changes  noticed  in  autopsies  in  the  composition  of  the  bile,  in 
order  to  direct  the  attention  of  observers  to  the  examination  of  the 
fluid  excreted,  either  by  vomiting,  or  by  stools,  in  the  course  of 
diseases.  We  should  hope  that  accurate  observations  of  the  bile, 
especially  when  vomited  in  an  almost  pure  state  and  in  considera- 
ble quantities,  will  furnish  interesting  results,  and  throw  much 
light,  in  many  cases,  on  diagnosis.  We  are  equally  persuaded 
that  the  chemical  analysis  of  bilious  stools  and  other  stercoral 
matters,  will  one  day  furnish  signs  of  great  value  in  the  diagnosis 
of  diseases  of  the  liver,  the  intestines  and  all  the  other  digestive 
organs. 

The  only  changes  hitherto  noticed  in  the  biliary  secretion  and 
excretion,  have  reference  either  to  its  increase  in  bilious  flux,  or 
to  its  suppression  in  cases  of  jaundice  arising  from  occlusion  of  the 
excretory  ducts  by  calculi  contained  within  them,  or  by  the  com- 
pression of  a  tumor.  Whenever  any  cause  obstructs  the  excre- 
tion of  the  bile,  the  alvine  matter  loses  its  natural  color,  and 
becomes  of  a  grayish  tint ;  while  the  fluids  excreted,  and  particu- 
larly the  urine,  assume  the  color  of  the  bile,  which  also  diffuses 
itself  over  the  whole  skin,  and  exists  to  a  considerable  extent  in 
all  the  solids.  Chemical  analysis  discovers  in  the  urine,  in  the 
serum  of  the  blood,  and  in  most  of  the  humors  of  these  subjects, 
some  of  the  materials  that  enter  into  the  composition  of  the  bile, 
such  as  the  coloring  matter  and  perhaps  the  picromel.  The  yellow 
color,  so  remarkable  after  death  in  all  parts  of  the  body,  proves 
also,  that  all  the  organs,  cartilages,  tendons  and  even  bones,  par- 
ticipate in  the  general  impregnation. 

4.  But  however  obscure  the  changes  that  take  place  in  the  secre- 
tion of  the  bile,  those  that  disease  produces  in  the  secretion  of  the 
pancreatic  fluid  are  still  more  so.     Is  there  any  increase  of  this 
secretion  in  certain  aqueous  fluxes  of  the  intestines,    in   serous 
diarrhoea,  for  example  ?     Does  the  ptyalism  that  takes  place  in 
certain  abdominal  affections  indicate,  as  has  been  asserted,  that 
the  secretion  of  the  pancreatic  fluid  is  diminished  or  suppressed  ? 
May  not  the  formation  of  calculi  in  the  pancreatic  duct,  give  rise 
to  accidents  analogous  to  those  observed  in  hepatic  and  nephritic 
colics?     In  the  present  state  of  the  science  it  is  impossible  to  an- 
swer these  questions. 

5.  The  secretion  of  the  urine  is  one  of  the  most  important,  both 
on  account  of  its  quantity  and  because  its  changes  are  readily 
appreciated.     In  health,   the  quantity  of  the  urine  is  about  the 
same  every  day,  though  its  increase  or  diminution  depends  upon 
the  abundance  of  the  other  excretions,  upon  the  quantity  of  food 
and  drink,  and  upon  changes  of  temperature.     At  the  time  of  its 
excretion,  the  urine  is  warm,  transparent,  of  a  pale  yellow  color, 
and  slightly  acid.     It  has  an  odor  peculiar  to  itself  unaccompa- 
nied with  fetidness.     It  is  salt  and  bitter  to  the  taste,  and  has  a 
specific  gravity  of  1.018.     It  often  becomes  turbid  upon  cooling, 
recovering  its  transparency  after  its  floating  particles  are  precipita- 
ted.    After   two  or  three  days  it  becomes  ammoniacal  and  fetid. 


SYMPTOMS.  211 

The  urine  of  the  healthy  man  presents  numerous  changes  in  its 
physical  and  chemical  properties,  according  as  it  is  secreted  before, 
during,  or  after,  meals,  and  particularly  according  to  the  quantity 
and  nature  of  the  food  and  drinks.  Certain  substances  change,  in 
a  remarkable  manner,  its  color  and  its  odor;  it  becomes  blackish 
after  the  simultaneous  use  of  rhubarb  and  iron,  cassia  and  the 
chalybeates;  sorrel  broth,  and  the  root  of  the  strawberry  and 
madder,  change  its  color  to  red  ;  turpentine  gives  it  the  smell  of  the 
violet,  and  asparagus,  an  intolerable  fetor. 

In  disease,  the  excretion  of  this  urine  and  this  fluid  itself  undergo 
important  changes. 

The  excretion  of  the  urine  may  be  attended  with  pain,  as  in 
blennorrhagia  ;  dysuria*  is  where  it  is  attended  with  difficul- 
ty, as  in  the  contraction  of  the  canal  of  the  urethra  ;  stran- 
gury (stranguria)  f  where  it  flows  guttatim,  a  symptom  which 
frequently  accompanies  vesical  catarrh ;  ischuria  $  or  the  reten- 
tion of  the  urine,  is  where  its  excretion  is  impossible ;  and  vesi- 
cal tenesmus,  where  there  is  a  continual  and  painful  desire  to 
make  water,  and  where  the  urine  is  excreted  in  small  quantities 
at  a  time  and  with  a  sensation  of  burning.  The  excretion  some- 
times occurs  involuntarily,  as  in  certain  spasmodic  affections  of  the 
bladder,  in  which  it  takes  place  at  the  moment  of  the  desire,  and 
in  spite  of  the  efforts  of  the  patient  to  prevent  it.  In  other  cases 
in  which  the  excretion  of  the  urine  is  involuntary,  the  patient  is 
unconscious  of  it,  as  in  many  diseases  accompanied  with  delirium. 
There  are  other  cases  in  which,  instead  of  being  excreted  at  cer- 
tain intervals  and  in  a  certain  quantity,  the  urine  flows  drop  by 
drop  without  interruption ;  this  is  called  incontinence  of  urine. 
Ordinarily,  the  urine  is  only  excreted  in  this  manner  when  the 
bladder  has  acquired  all  the  distension  of  which  it  is  capable, 
and  its  excretion  is  then  said  to  take  place  by  regorgement.  In 
another  class  of  cases  the  urine  flows  interruptedly  in  jets,  and  its 
excretions  ceases  and  recommences  many  times  before  being  com- 
plete ;  this  symptom  often  arises  from  the  presence  of  calculi  or 
clots  of  blood  in  the  bladder,  which  at  intervals  obstruct  the  neck 
of  this  viscus ;  it  is  also  of  frequent  occurrence  in  certain  spas- 
modic affections.  The  excretion  of  the  urine  is  also  subject,  in 
disease,  to  deviations.  We  have  known  it  in  perviousness  of  the 
urachus,  to  escape  at  the  navel,  and,  in  the  different  forms  of  vesi- 
cal or  urethral  perforation,  to  find  its  way  out  through  the  anus, 
the  scrotum  and  the  neighboring  parts,  and  the  vulva.  Some 
authors  have  mentioned  still  more  remarkable  deviations  of  the 
urine,  such  as  urinous  salivation,  perspiration  and  vomiting. 
Boerhaave  thought  he  even  discovered  urine  in  the  cerebral  ventri- 
cles. These  last  statements,  however,  can  hardly  be  received 
with  implicit  confidence.  It  may  be  that  the  fluids  of  which  these 
authors  speak,  have  had  the  urinous  odor  and  color,  but  we  may 

*  JvnovQia;  3v?,  with  difficulty  ;  OVQOV,  urine, 
t   2T()uyyovoiu  •  oT^aySj  drop  j   oi)(jojr,  urine. 
,  1  retain;  OVQOV,  urine. 


212  'SYMPTOMS. 

well  donbt  whether  this  phenomenon  is  owing  to  the  actual  pres- 
ence of  urine. 

The  urine,  considered  in  itself,  presents  numerous  changes  in 
sickness.  These  changes  relate  to  its  quantity  and  its  physical 
and  chemical  properties.  The  quantity  of  the  urine  increases 
sometimes  in  the  decline  of  diseases.  It  is  unusually  great  in  dia- 
betes, and  diminishes  in  dropsy.  Entire  suppression  of  the  urine 
never  takes  place,  except  in  cases  of  occlusion  of  both  the  ureters 
simultaneously,  or  of  one  only ;  and  in  cases  in  which,  either  ow- 
ing to  congenital  formation,  or  to  complete  atrophy  of  one  of  these 
organs,  but  one  kidney  exists.*  In  a  greater  part  of  the  nervous 
affections,  the  urine  is  colorless,  less  acid  and  often  neutral.  It  is 
generally  red  and  unusually  acid  at  the  commencement  of  acute 
diseases,  and  brown,  or  black,  in  many  fatal  diseases.  The  latter 
color  generally  arises  from  the  coloring  matters  of  the  blood  con- 
tained in  the  urine.  It  may  also  be  owing,  according  to  some 
chemists,  to  the  accidental  presence  in  the  urine,  of  a  peculiar  acid, 
called  melanic.  Lastly,  the  urine  may  become  milky  white  in 
cases  in  which  it  contains  either  pus,  or  a  fatty  substance,  that  can 
easily  be  separated.  But  whatever  its  color,  the  urine  may  be 
transparent  or  turbid.  The  urine  is  said  to  be  transparent  when 
it  preserves  its  translucency,  or  recovers  it  after  momentarily  los- 
ing it  in  cooling.  Turbid  urine  is  that  which  remains  so,  and 
does  not  become  transparent  by  the  precipitation  of  the  particles 
suspended  in  it.  Opacity  of  the  urine  is  caused  by  the  presence  of 
mucus,  blood,  albumen,  pus,  etc.,  but  more  generally  by  an  excess 
of  uric  acid,  urate  of  ammonia,  or  of  the  alkaline  phospates.  The 
ancients  termed  the  urine  jumenteuse^  when  it  is  turbid  and  con- 
tains at  the  same  time  corpuscules  or  opaque  particles  floating  in 
it.  This  expression,  however,  though  much  used  by  old  writers, 
has  no  very  definite  meaning,  and  may  be  applied  to  urine  differ- 
ing very  much  in  chemical  properties.  The  smell  of  the  urine 
becomes  ammoniacal  in  chronic  catarrh  of  the  bladder.  In  certain 
adynamic  diseases,  and  in  many  vesical  affections  it  emits  a 
brackish  smell.  The  discolored  urine  excreted  during  the  declen- 
sion of  hysterical  attacks,  and  in  the  first  stage  of  intermittent 
fevers  in  almost  inodorous.  In  inflammatory  diseases,  on  the  con- 
trary, it  emits  a  very  powerful  odor.  In  diabetes  mellitus  the 
urine  acquires  after  fermentation  an  alcoholic  smell.  In  Bright's 
disease,  it  has  sometimes  the  smell  of  boiled  beef.  This  latter 
smell  is  occasionally  perceived  in  the  urine  of  healthy  persons, 
especially  after  profuse  perspiration.  In  many  acute  diseases,  the 
urine  differs  from  day  to  day  with  regard  to  its  color,  transparency, 
sediments,  etc. ;  this  is  termed  variable  urine.  In  certain  gangren- 
ous inflammations  the  urine  is  almost  cold  at  the  moment  of  excre- 
tion. A  diminution  of  its  temperature  has  also  been  noticed  in  the 
cold  stage  of  intermittent  fever. 

*  Vid.  our  Treatise  on  Nephritis,  Archiv.  Gen.  de  Med.  v.  1,  3d  Ser.  pp.  5 
and  477. 

f  Jumentum,  beast  of  burden  ;  urine  that  resembles  that  of  mules,  horses,  etc. 


SYMPTOMS.  213 

Little  is  known  of  the  taste  of  urine  in  a  state  of  disease,  on  ac- 
count of  the  natural  repugnance  to  experiments  of  this  nature. 
We  know,  however,  that  in  diabetes  mellitus  it  has  a  sweet  taste, 
and  that  it  is  almost  insipid  after  the  hysterical  paroxysm. 

M.  Rayer,  has  made  numerous  experiments  upon  the  specific 
gravity  of  the  urine,  which  varies,  in  health,  according  as  it  has 
been  secreted  after  fasting,  during  or  after  meals,  etc.  He  fixed 
the  mean  specific  gravity  of  the  urine  excreted  at  the  hour  of  wak- 
ing in  the  morning,*  at  1.018,  that  of  water  being  1.000.  The 
same  physician  found  that  in  diabetes  mellitus,  the  density  of  the 
urine  is  much  more  considerable,  while  it  is  less  in  diabetes  insip- 
idus.  In  Bright's  disease,  except  in  the  first  or  acute  stage,  it  is 
generally  lower  than  in  health.  The  specific  gravity  of  the  urine 
may  be  a  circumstance  of  practical  advantage  in  diabetes  mellitus. 
Examined  at  different  hours  of  the  day  before  and  after  meals,  it 
may  indicate  the  increase  or  diminution  of  the  sugar. 

The  elements  of  the  urine  undergo  variation  in  disease  to  a 
greater  or  less  extent.  Thus,  the  quantity  of  water  may  become 
very  great,  as  in  diabetes  msipidus ;  in  some  nervous  affections  the 
urine  is  almost  entirely  aqueous.  The  other  elements  of  the  urine 
increase,  on  the  contrary,  in  proportion,  in  most  febrile  diseases. 
The  quantity  of  urea  rarely  increases  in  sickness,  although  it  is 
very  common,  as  M.  Rayer  has  remarked  to  find  it  existing  in  a 
less  proportion,  which  arises,  perhaps,  as  much  from  abstinence 
from  food,  as  from  the  influence  exerted  by  disease  itself  on  the 
renal  secretion.  It  has  not  yet  been  proved  that  the  quantity  of 
urea  is  diminished  in  diseases  of  the  liver ;  but  in  the  granular 
affection  of  the  kidneys  its  diminution  is  an  almost  invariable  phe- 
nomenon. The  uric  acid,  which  enters  into  the  composition  of  the 
urine  in  the  proportion  a  thousandth  in  health,  may  increase  in  a 
remarkable  manner;  this  has  been  particularly  observed  during 
the  progress  of  rheumatic  and  gouty  affections,  and  many  inflam- 
matory diseases,  etc.  This  excess  of  uric  acid  often  has  the  effect 
of  producing  red  gravel  in  different  parts  of  the  urinary  passages. 
This  acid  is  generally  found  in  combination  with  lime,  soda,  and 
particularly  ammonia.  There  may  also  be  a  disproportion  of 
phosphoric  acid  and  the  phosphates  of  lime  and  magnesia  in  the 
urine,  which  we  notice  in  cases  of  rachitis,  molhties  ossium,  and 
in  some  kinds  of  gravel ;  in  all  these  cases  the  urine  is  more  or  less 
turbid.  The  salts  of  soda,  potash,  and  ammonia,  are  sometimes 
found  in  more  considerable  quantities,  and  render  the  urine  either 
neutral  or  alkaline.  The  alkalinity  of  the  urine  has  also  been 
ascertained  in  phosphatic  gravel,  in  certain  cases  of  Bright's  disease 
and  frequently  in  chronic  nephritis,  as  in  cases  of  old  men  enfeebled 
by  privation  and  misery.  It  has  been  stated  that  alkalinity  of  the 
urine  is  frequent  in  the  course  of  typhoid  fevers.  M.  Rayer  as- 
serted that  out  of  fifty  cases  he  formed  the  urine  alkaline  but  twice, 
and  for  the  space  of  three  days  only,  and  the  observations  of  M. 

*  Maladies  des  Reins,  t.  1,  p.  71. 


214  SYMPTOMS. 

Rostan  agree  on  this  point  with  those  of  M.  Rayer.  Brodie  and 
Hunkel  have  remarked  the  alkalinity  of  the  urine  after  traumatic 
or  other  lesions  of  the  vertebral  column ;  but  as  this  has  been  con- 
tradicted, further  observation  will  be  necessary  to  determine  it. 

Mucus,  which  is  one  of  the  natural  ingredients  of  the  urine,  may 
become  developed  in  unusual  quantities.  We  observe  this  in  some 
inflammations  of  the  bladder,  in  inflammations  of  the  pelvis  of 
the  kidneys,  and  of  the  ureters. 

The  urine  may  also  become  changed  by  the  presence  of  different 
substances  foreign  to  its  normal  composition.  Thus,  sulphur  has 
been  found  in  it,  and  rare  cases  are  mentioned  of  phosphorescent 
urine  which  shines  in  the  dark  at  the  moment  of  its  emission.  We 
shall  not  here  refer  to  the  hippuric,  oxalic,  benzoic,  carbonic,  buty- 
ric and  prussic,  xanthic  and  cystic,  acids  which  have  been  acci- 
dentally discovered  in  the  urine  under  the  influence  of  various  and 
often  inappreciable  causes.  But  there  are  other  substances  which 
we  find  more  commonly  in  the  urine,  whose  existence  in  it  is  easy 
to  prove  and  which  furnish  signs  too  important  to  be  omitted  ;  such 
are,  blood,  albumen,  sugar,  pus,  semen,  fecal  matters,  gas,  intesti- 
nal worms,  gravel,  and  many  other  foreign  bodies. 

The  urine  sometimes  contains  blood  which  may  come  from  the 
different  parts  of  the  urinary  passages.  It  varies  in  quantity,  and 
is  more  or  less  thoroughly  mixed  with  the  urine ;  sometimes  is  in 
a  fluid  state,  and  sometimes  exists  in  the  form  of  blackish  clots. 
Occasionally  it  is  discharged  in  the  form  of  full  or  tubulous  fila- 
ments, which  have  been  mistaken  for  worms.  This  clotted  form 
indicates  the  coagulation  of  blood  in  the  urethra  previously  effused 
in  the  kidney  itself.  Bloody  urine,  when  left  to  repose,  forms 
a  blackish  sediment  composed  of  bloody  globules  and  fibrine. 
The  quantity  of  the  blood  is  sometimes  so  small  that  we  can 
ascertain  the  existence  of  the  globules  only  by  the  aid  of  the 
microscope.  The  presence  of  blood  in  the  urine  is  almost  al- 
ways an  indication  of  a  cancerous  or  calculous  affection  of  some 
part  of  the  urinary  passages,  and  particularly  the  kidneys  or  blad- 
der;  it  has  been  also  observed  in  scurvy,  in  severe  cases  of  variola, 
and  in  pestilential  diseases. 

The  urine  may  contain  albumen  in  a  greater  or  less  quantity, 
the  presence  of  which  we  can  ascertain  by  the  application  of  heat 
or  nitric  acid,  which  produce  a  white  and  flocculent  precipitate. 
The  presence  of  a  very  great  quantity  of  albumen  in  the  urine, 
together  with  a  perceptible  diminution  of  its  specific  gravity  and 
of  the  proportion  of  urea  and  of  the  salts  which  it  contains,  con- 
stitutes the  most  important  sign  of  that  species  of  dropsy  connected 
with  disease  of  the  kidneys,  first  described  by  Dr.  Bright.  The 
urine  is  also  albuminous,  but  generally  to  a  much  less  degree,  in 
the  dropsy  that  succeeds  scarlatina  and  the  decline  of  certain 
acute  diseases,  as  Dr.  Martin  Solon  has  proved.  The  urine  may 
contain  at  the  same  time  albumen,  blood  and  pus  in  grave  affec- 
tions of  the  urinary  organs  and  in  some  diseases  of  the  prostate. 

The  opinion  was  for  a  long  time  entertained,  and  even  recently, 


SYMPTOMS.  215 

by  men  of  great  merit,  that  the  urine  of  nursing  women  or  of 
women  soon  after  parturition,  may  contain  milk.  These  opin- 
ions, however,  were  founded  upon  no  exact  observation  or  experi- 
ment, and  there  is  reason  to  suspect  that  the  physicians  and 
chemists  that  entertained  them,  were  deceived  by  the  turbid 
appearance  of  the  fluid,  by  the  presence  of  foreign  matter,  arid 
particularly  pus  or  a  fatty  substance.  Authors,  and  especially 
Prout,  have  spoken  of  chylous  urine,  that  is  to  say,  urine  contain- 
ing the  organic  principles  of  chyle,  visible  with  the  aid  of  the 
microscope;  but  the  characters  of  this  kind  of  urine  are  not  yet 
clearly  ascertained,  and  besides,  the  chylous  appearance  may  be 
owing  to  the  presence  of  a  fatty  matter  in  the  urine.  Ancient 
writers  mentioned  the  existence  of  fat  or  oil  in  the  urine,  during 
the  course  of  chronic  diseases  with  progressive  emaciation ;  but  this 
assertion  has  not  been  verified,  and  M.  Rayer  sought  in  vain  for 
these  substances  in  the  urine  of  phthisical  patients. 

Sugar  is  also  found  to  exist  in  the  urine.  This  has  not  only 
been  proved  by  the  taste,  but  has  been  verified  by  chemists  in  a 
more  satisfactory  manner,  by  the  spontaneous  fermentation  of  the 
urine  and  by  the  actual  separation  of  the  sugar  from  its  other  ele- 
ments. The  presence  of  sugar  in  the  urine  is  a  pathognomonic 
sign  of  that  species  of  diabetes  termed  mellitus.  This  urine  has 
a  specific  gravity  greater  than  that  of  the  healthy  individual, 
although  it  contains  less  urea  and  less  salts. 

Urine  containing  pus  presents,  even  at  the  moment  of  its  emis- 
sion, a  turbid  and  milky  appearance.  Left  in  a  quiescent  state  it 
becomes  transparent,  and  an  opaque  deposit  collects  in  its  lower 
part,  forming  a  stratum  varying  in  thickness.  This  urine  decom- 
poses rapidly  and  becomes  alkaline.  Pus  is  generally  readily  dis- 
tinguished by  its  qualities  where  it  exists  in  the  urine  in  any 
considerable  quantity  ;  but  when  its  proportion  is  small,  and  when 
mingled  with  mucus  and  salts,  its  presence  is  very  difficult  to 
prove.  Chemical  and  microscopic  examination  may  be  resorted 
to  under  such  circumstances,  with  advantage,  but  in  the  pres- 
ent state  of  the  science,  as  we  have  before  remarked,  it  cannot  inspire 
entire  confidence.  The  ascertained  presence  of  pus  in  the  urine 
is  always  an  alarming  symptom  in  prognosis,  and  very  important 
in  diagnosis.  It  is  a  certain  sign  either  of  inflammation  of  the 
kidneys  or  bladder,  or  of  an  abscess  formed  near  the  urinary 
organs  and  opening  into  their  cavity.  Examination  of  the  symp- 
toms preceding  the  emission  of  purulent  urine  and  of  the  organs 
themselves,  enable  us  frequently  to  discover  the  parts  in  which  the 
pus  has  been  formed. 

In  the  course  of  blennorrhagia  the  urine  sometimes  acquires  con- 
tagious properties,  doubtless  owing  to  the  particles  of  urethral 
mucus  which  it  carries  away  with  it.  Mertens,  Astruc  and  Chaus- 
sier,  have  seen  individuals  that  have  contracted  a  blennorrhagic 
ophthalmia  in  consequence  of  bathing  the  eyes  with  urine  in  the 
course  of  urethritis. 

The  urine  sometimes  contains,  also,   small  solid  concretions, 


216  SYMPTOMS. 

some  of  which  are  as  fine  as  sand,  while  others  are  somewhat 
larger  and  equalling  grains  of  hemp  seed  in  size.  The  first  kind  is 
excreted  by  the  patient  unconsciously.  The  second  indicates  its 
passage  through  the  canal  of  the  urethra  by  pain  more  or  less 
acute,  and  sometimes  by  a  sensation  of  tearing,  according  as  the 
surface  of  these  particles  is  smooth  or  rough,  and  according  as  their 
bulk  is  greater  or  less.  In  somes  cases  their  expulsion  is  attended 
with  no  pain,  and  the  patient  is  only  conscious  of  their  existence 
from  the  noise  of  their  fall  into  the  vessel  that  receives  them. 
These  concretions  are  generally  formed  in  the  kidneys,  and  their 
presence  in  the  urine  should  always  lead  us  to  fear  that  they 
actually  exist  in  the  kidneys,  and  that  others  are  in  process  of  for- 
mation. In  some  rare  instances  these  concretions  are  convex  on 
one  side  and  concave  on  the  other,  and  represent  a  portion  of  the 
external  layer  of  a  calculus  which  has  exfoliated  in  the  bladder, 
and  are  pathognomic  of  its  presence. 

The  saline  concretions  which  form  in  the  urinary  passages  vary 
considerably  in  regard  to  physical  and  chemical  properties.  The 
smallest  of  them,  those  that  do  not  exceed  a  pea  in  size,  are  termed 
gravel ;  all  of  greater  bulk  than  this  are  called  calculi.  Their 
number  is  more  or  less  considerable,  and  is,  generally,  in  inverse 
ratio  to  their  volume.  They  are  round,  oval  or  irregular  in  form, 
sometimes  presenting  a  rough  surface  (calculs  muraux).  Their 
surface  often  presents  one  or  more  faces,  an  almost  certain  indica- 
tion of  the  simultaneous  existence  of  several  stones  in  some  part 
of  the  urinary  passages.  There  are  cases  of  gravel  or  calculi 
that  break  with  the  least  pressure,  while  others  have  the  resistance 
and  firmness  of  the  hardest  stone.  A  greater  part  of  the  urinary 
concretions  are  formed  of  uric  acid,  and  are  then  of  a  red  color 
bordering  more  or  less  upon  yellow.  Next  in  order  of  frequency 
are  calculi  of  the  ammoniaco-magnesian  phosphate,  crystal ized 
into  prisms  and  of  a  whitish  color.  After  these  come  calculi  of 
the  oxalate  of  lime  which  are  black,  brown  or  grayish ;  after 
these,  calculi  of  the  phosphate  of  lime  and  magnesia ;  and  lastly, 
M.  Magendie  has  described  a  hairy  gravel,  of  which  he  gives  three 
instances  ;  in  these  cases,  hairs  had  formed  upon  the  surface  of  the 
saline  concretions,  probably  proceeding  from  some  cyst  opening 
into  some  of  the  urinary  passages. 

There  have  also  been  discovered  in  the  urine  masses  of  tuber- 
culous and  encephaloid  matter  coming  from  the  kidneys,  and  fur- 
nishing in  some  cases  very  important  diagnostic  signs. 

In  cases  of  seminal  loss,  of  urethral  strictures  and  diseases  of 
the  prostate  and  of  the  ejaculatory  ducts,  the  semen  may  flow  back 
into  the  bladder,  and  be  excreted,  mingled  with  urine.  From  the 
experiments  of  M.  Orfila,  it  appears  that  the  urine  excreted  imme- 
diately, or  some  hours,  after  a  pollution  or  an  ejaculation,  carries 
with  it,  and  consequently  contains,  spermatozoa  which  had  re- 
mained in  the  canal  of  the  urethra.  However  few  in  number 
they  may  be,  they  always  sink  to  the  bottom  of  the  vessel,  and 
can  be  readily  distinguished  with  the  microscope. 


SYMPTOMS.  217 

In  cases  in  which  there  is  a  communication  between  the  urinary 
passages  and  the  rectum,  or  a  portion  of  an  intestine,  the  urine 
may  contain  fecal  matters,  gas  may  escape  through  the  urethra, 
and  worms  may  also  be  expelled  in  the  same  manner.  We  may 
also  explain  in  the  same  way  the  existence  of  foreign  bodies  in  the 
bladder,  such  as  pins,  fruit  seeds,  &c.,  which  have  been  known  to 
form  the  nuclei  of  vesical  calculi.  Sometimes  too,  foreign  bodies 
find  their  way  into  the  urinary  passages  through  an  external 
wound,  or  are  introduced  by  the  urethra.  The  presence  of  sub- 
stances in  the  urine,  which  can  only  come  from  the  intestines  is,  in 
most  cases,  a  pathognomonic  sign  of  grave  and  deep-seated  altera- 
tions which  no  other  symptom  could  have  revealed. 

In  cases  in  which  a  perforation  has  taken  place  between  the 
bladder  and  rectum,  it  is  often  possible,  by  introducing  a  probe  into 
the  bladder  and  a  finger  into  the  intestine,  to  feel  it  ;  it  may  even 
happen  that  the  opening  of  the  communication  is  sufficiently  large 
to  admit  the  passage  of  the  finger  itself  from  the  rectum  into  the 
bladder. 

A  great  many  substances  administered  under  the  name  of  med- 
icines and  introduced  into  the  stomach,  may  be  discovered  in  the 
urine.  Chemists  assert  that  they  have  found,  in  the  urine,  iodine, 
mercury,  arsenic,  iron,  the  acetate  and  tartrate  of  potash,  the 
alkaline  sulphates  and  carbonates,  the  nitrate  of  potash,  the  sul- 
phate of  quinine,  etc. 

The  urine,  left  to  itself,  does  not  generally  preserve  that  homo- 
geneousness  which  it  has  at  the  moment  of  excretion.  Many  of 
its  elements  become  separated  Irom  its  mass,  and  form  pellicles, 
deposits  and  various  suspensions.  To  thoroughly  appreciate  these 
various  phenomena,  it  is  necessary  to  place  the  urine  in  a  trans- 
parent vessel  at  the  very  moment  of  excretion,  and  leave  it,  for  five 
or  six  hours  at  least,  in  a  state  of  repose. 

The  pellicle,  cream  or  crown  (urince  corona,  cremor)  is  a  sort  of 
very  thin  membrane  that  forms  upon  the  surface  of  the  urine. 

The  suspension  which  begins  to  appear  in  the  urine  some  hours 
after  excretion,  is  of  two  kinds  ;  the  first,  called  nebula  (nubecula, 
nubcs),  is  that  which  forms  near  the  superior  surface  of  the  fluid; 
the  second,  which  settles  near  the  bottom,  is  called  encLorcma* 
We  may  also  observe  in  some  cases  a  mean  suspension  in  the 
urine,  midway  between  the  surface  and  the  bottom,  which  has  re- 
ceived no  particular  designation.  The  urine  presents  these  various 
suspensions  in  most  acute  diseases.  According  to  some  authors,  the 
suspension  is  more  or  less  removed  from  the  bottom  of  the  vessel, 
in  proportion  as  the  disease  is  nearer  its  termination  or  otherwise. 
This  rule,  however,  has  numerous  exceptions. 

Deposits,  also  called  sediment  (sedimentum,  hypostasis),  f  are 
caused  by  the  heaviest  substances  reuniting  at  the  bottom  of 
the  vessel,  and  forming  a  stratum  of  greater  or  less  thickness. 


ua,  from  uuaytw,  1  raise. 
,  from  fTrormiw,  I  am  under. 

19 


218  SYMPTOMS. 

Sediment  does  not  generally  appear  till  towards  the  decline  of  acute 
diseases.  It  does  not  always  form  at  this  period,  but  it  is  rare  to 
observe  it  at  any  other.  Ancient  writers  laid  much  stress  upon 
the  importance  of  sediment  as  a  diagnostic  sign  of  intermittent 
fevers.  They  considered  this  phenomenon  invariable  in  the  third 
stage  of  the  paroxysms.  Sediment  not  only  collects  upon  the 
bottom  of  the  vessel  that  receives  the  urine,  but  forms  often  upon 
its  lateral  walls  a  thin  stratum,  sufficiently  defined,  however,  to 
give  the  fluid  a  turbid  appearance.  Upon  inclining  the  vessel,  this 
disappears,  and  we  then  see  on  one  side  perfectly  transparent  urine 
underneath  the  deposit,  and  on  the  other,  the  deposit  alone  forming 
an  opaque  coat  upon  the  walls  of  the  vessel.  The  sediment  is 
generally  of  a  whitish  or  grayish  color ;  as  frequently,  perhaps,  in 
intermittent  fever^  (sedimentum  lateritium),  it  is  of  a  rosy  color, 
or  the  color  of  brick  dust.  It  is  often  brown  or  black  in  jaun- 
dice and  some  acute  fatal  diseases ;  and  in  a  few  extremely  rare 
cases,  of  a  bluish  color,  owing  either  to  the  presence  of  a  peculiar 
substance,  called  by  M.  Braconnot  cyanourine,  or  to  hydrocyanate 
of  iron,  according  to  the  observations  of  M.  M.  Julia,*  Battf  and 
Mojon.  J  The  sediment  often  has  the  appearance  of  dust,  or  of 
meal  or  bran  coarsely  ground ;  this  is  the  furfuraceous  sediment, 
(sedimentum  furfuraceurri)  $.  At  other  times  it  is  formed  of  a 
mucous  matter  either  united  into  flocculi,  or  collected  at  the  bottom 
of  the  vessel  in  an  even  and  semi-transparent  stratum.  This  is 
the  mucous  sediment.  We  designate  by  the  epithet  sandy  or 
gravelly,  the  sediment  that  contains  sand  or  gravel  (sedimentum 
arenosum).  Purulent  sediment  is  that  consisting  of  pus,  etc. 
Deposits,  nebulas,  and  pellicles  that  form  in  the  urine  have  been 
examined  by  the  microscope  and  subjected  to  chemical  analysis. 
The  nature  of  these  various  urinary  products  varies  according  as 
the  urine  itself  is  acid  or  alkaline.  In  acid  urine,  the  nebulas  and 
enaeoremata  are  formed  by  thin  lamellae  of  epithelium,  urates, 
uric  acid  and  mucus.  The  yellow,  reddish  or  red  sediments  are 
formed  of  uric  acid  or  urate  of  ammonia,  distinguishable  from 
each  other  by  their  modes  of  crystallization  which  the  micro- 
scope enables  us  to  determine  with  precision.  Alkaline  urine,  more 
or  less  discolored,  is  generally  accompanied  by  a  white  or  slightly 
yellow  sediment  disposed  into  regular  crystals,  or  forming  an 
amorphous  and  pulverulent  mass  :  this  sediment  is  generally  com- 
posed of  phosphate  of  lime  and  the  ammoniaco-magnesian  phos- 
phate, mingled  often  with  pus  adulterated  by  ammonia,  which 
gives  it  a  viscous  or  mucous  appearance.  We  may  also  find  in  it 
sanguineous  globules,  spermatozoa,  the  coloring  matters  of  the  bile  , 
and  occasionally  various  salts  of  which  lime  forms  the  base,  etc. 

*  Journal  de  Chimie,  vol.  1,  p.  330. 

f  De  Urina  Sedimentum  Ceruleum  Demittente,  1809. 

j  Journal  de  Medec.,  vol.  72,  p.  174. 

§  Furfur,  meal. 


SYMPTOMS.  219 


$  III.    Excretions. 

Having  examined  in  succession  the  principal  morbid  phenomena 
presented  by  the  secretions,  it  remains  to  say  a  few  words  with 
regard  to  the  derangements  of  the  excretions,  independently  of 
those  of  the  secretions. 

The  excretions  which  are  under  the  influence  of  the  will,  are 
those  alone  of  sufficient  importance  to  be  discussed  in  this  place. 
These  excretions  may  become  in  disease  more  or  less  frequent  than 
in  health,  and  may  be  accompanied  with  considerable  efforts  or 
be  effected  too  easily.  They  may  be  involuntary,  as  in  many  grave 
diseases,  and  on  the  other  hand,  the  will  may  be  unable  to  promote 
them,  as  in  cases  of  retention  of  the  urine  and  occlusion  of  the 
rectum  by  hardened  faeces.  Sometimes  the  desire  of  excretion  is 
continual,  painful  and  almost  ineffectual,  as  in  tenesmus  of  the 
rectum  or  bladder.  We  can  here  only  refer  to  these  symptoms, 
as  they  have  been  discussed  elsewhere,  but  must  confine  ourselves 
to  the  consideration  of  the  phenomena  which  have  not  yet  been 
enumerated ;  such  are  those  which  arise  from  the  occlusion  of  the 
excretory  canals,  whether  these  canals  are,  or  are  not,  provided 
with  sphincters,  and  whether  the  excretions  are  involuntary  or 
otherwise. 

The  causes  which  produce  occlusion  of  these  canals  are  very 
various,  but  may  be  divided  into  three  classes.  The  canal  is 
sometimes  choked  by  an  obstacle  contained  in  its  cavity,  a  calcu- 
lus, for  example ;  sometimes  its  cavity  is  obliterated  by  the  thick- 
ening of  its  walls,  and  sometimes  by  an  external  compression,  as 
of  a  neighboring  tumor.  This  occlusion  is  followed  by  various 
results.  1.  The  excretions  of  the  fluid  is  prevented.  This  sup- 
pression is  often  difficult  to  prove  during  life  in  cases  in  which  the 
secretory  organs  being  double,  like  those  of  the  urine,  the  occlu- 
sion of  one  of  the  excretory  canals  does  not  entirely  interrupt  the 
excretion  of  the  fluid ;  and  in  those  cases  in  which  the  functions 
of  the  secretory  organs  are  of  minor  importance  or  merely  auxil- 
iary. But  whenever  the  viscus  to  which  the  obliterated  canal 
belongs  is  single,  and  plays  an  important  part  in  the  economy,  as 
the  liver,  for  example,  the  occlusion  of  the  canal  is  soon  followed 
by  remarkable  phenomena,  such  as  acute  pains,  a  yellow  color  in 
the  skin  and  urine,  discoloration  of  the  faecal  matters  and  various 
derangements  of  the  digestive  functions.  2.  Another  consequence 
of  occlusion  is  distension  of  the  canal  from  its  source  to  the  obsta- 
cle, and  after  a  certain  time  its  contraction  and,  sometimes,  entire 
obliteration  from  the  obstacle  to  its  point  of  termination.  This 
distension  is  apparent  in  the  duct  of  Steno,  vasa  deferentia  and  la- 
crymal  sac,  but  entirely  escapes  our  direct  observation  whenever 
the  organ  is  deeply  seated,  as,  for  example,  the  liver,  kidney  and 
pancreas.  3.  The  progressive  distension  of  the  canals  by  the 
fluids  which  incessantly  flow  into  them,  represents  a  force  which 
has  a  tendency  to  remove  the  obstacle  which  produces  the  occlu- 


220  SYMPTOMS. 

sion,  to  raise  the  tumor  which  presses  upon  the  canal,  to  dilate  its 
lateral  walls,  or  to  push  before  it  the  foreign  body  contained  in  it. 
In  this  last  case,  the  distension  of  the  canal,  as  far  as  the  calculus, 
would  seem  to  favor  its  progression  ;  for  it  is  difficult  to  suppose 
that  this  distension  being  so  considerable  as  far  as  the  calculus, 
might  not  extend  beyond  it.  And,  on  the  other  hand,  the  obstacle 
being  situated  at  ths  point  of  junction  of  two  portions  of  a  canal, 
one  of  which  is  continually  dilating  while  the  other  preserves  its 
natural  size,  may  frequently  fall  back  into  the  dilated  portion,  and 
by  its  displacement  suffer  the  collected  fluid  to  escape  through  the 
opening,  at  least  for  a  time.  4.  Lastly,  if  the  obstacle  is  neither 
pushed  out  nor  displaced,  death,  sooner  or  later,  may  be  the  conse- 
quence, as  in  cases  of  retention  of  urine,  intestinal  matters  and 
bile,  sometimes  by  the  rupture  of  the  canal  above  the  obstacle,  and 
sometimes,  by  the  retention  in  the  economy  of  substances  natural- 
ly excreted,  the  changes  they  undergo,  the  inflammation  they  pro- 
duce in  the  parts  containing  them,  and,  in  some  cases,  the  infection 
which  follows  their  absorption  into  the  circulatory  current. 


SECTION  SIXTH. 
Symptoms  furnished  by  Absorption. 

Having  examined  the  principal  disorders  of  the  secretions  and 
excretions,  it  remains  for  us  to  speak  of  those  presented  by  the 
different  species  of  absorption. 

We  may  remark,  in  the  first  place,  that  in  a  great  number  of 
cases,  derangements  of  absorption  may  be  confounded  with  those 
of  exhalation,  since  the  same  phenomenon,  the  accumulation  of 
serum  in  the  pleura  or  peritoneum,  for  example,  may  be  equally 
the  result  of  a  diminished  absorption  or  an  increased  exhalation. 

But  there  are  other  circumstances,  under  which  it  is  impossible 
not  to  recognize  the  effect  of  absorption.  The  gradual  or  rapid 
disappearance  of  pus  collected  in  a  bubo,  of  blood  extravasated 
under  the  skin  in  consequence  of  a  contusion,  of  serum  in  the 
cellular  tissue  or  in  a  serous  membrane,  are  evidently  phenomena 
which  absorption  alone  can  produce.  Primary  ulceration,  when 
not  arising  from  a  loss  of  substance,  or  from  the  separation  of  an 
eschar,  is  regarded  by  most  physicians  as  the  result  of  a  morbid 
absorption  acting  upon  the  solids  themselves,  and  carrying  away 
into  the  current  of  the  circulation  the  elements  of  which  they 
consist. 

It  is  generally  believed  that  there  is  between  the  different  absorp- 
tions an  analogy  similar  to  that  existing  between  the  different 
secretions. 

Thus,  when  absorption  is  very  active  in  the  digestive  canal, 
after  eating,  for  example,  the  exterior  absorption,  cutaneous  and 
pulmonary,  is  probably  diminished.  It  undoubtedly  becomes  more 
active  in  the  morning  before  breakfast,  since  at  this  period  of  the 


SYMPTOMS.  221 

day  the  gravity  of  the  body  is  increased,  as  was  proved  by  the 
experiments  of  the  celebrated  Sanctorius,  who,  from  the  zeal  and 
perseverance  with  which  he  devoted  himself  to  these  inquiries, 
deserves  to  have  disciples  and  rivals.  Many  practitioners  think, 
not  without  reason,  that  medicinal  preparations  left  to  the  action 
of  cutaneous  absorption,  mercurial  ointment,  for  example,  may  be 
administered  to  greater  advantage  at  this  hour  of  the  day. 

The  absorption  of  the  fat  contained  in  the  vesicles,  in  patients 
subjected  to  a  severe  course  of  diet,  comes  in  aid  of  the  opinion 
that  when  absorption  is  not  sufficiently  active  in  one  part,  it  in- 
creases in  another.  The  same  may  be  said  of  the  advantageous 
effects  that  sometimes  follow  a  rigorous  diet  in  the  treatment  of 
certain  engorgements ;  the  absorption  which,  for  want  of  sub- 
stance, is  not  effected  in  the  digestive  canal,  acts  with  more  energy 
in  other  parts,  and  may  cause  the  progressive  diminution  of  a 
hypertrophied  viscus,  as  well  as  that  of  the  whole  body.  Resolu- 
tion, which  we  shall  consider  in  another  place,  appears  to  be  noth- 
ing but  a  remedial  absorption. 

Besides  this  kind  of  equilibrium,  which  we  observe  in  disease 
between  the  secretions  on  the  one  hand  and  the  absorptions  on  the 
other,  there  are  also  cases  in  which  these  two  functions  act  in  con- 
cert. In  the  course  of  an  acute  phlegmasia,  pleurisy  for  example, 
so  long  as  the  disease  is  making  progress,  and  a  sero-purulent  fluid 
is  exhaled  in  the  pleura,  the  skin  is  dry  and  the  urine  excreted  in 
small  quantities.  But  when  the  absorption  begins  to  act  upon  the 
effused  liquid,  the  skin  often  becomes  moist  and  there  is  an  abun- 
dant flow  of  urine ;  analogous  phenomena  take  place,  and  are  more 
easily  observed  in  the  progressive  diminution  of  anasarca  and 
ascites.  In  these  cases,  exhalation  carries  away  through  the  skin, 
kidneys,  and  mucous  membrane  of  the  digestive  passages,  a  greater 
quantity  of  fluid,  in  proportion  as  absorption  takes  up  the  serum 
effused  in  the  serous  and  cellular  tissues.  The  considerable  in- 
crease of  certain  secretions,  the  urine,  for  example,  in  diabetes, 
and  abdominal  serum  in  ascites,  is  necessarily  connected  with  a 
similar  increase  of  absorption,  and  especially  the  pulmonary  or 
cutaneous  absorption.  The  excretion  of  from  twenty  to  forty 
pounds  of  urine  daily,  for  many  months  together,  in  diabetes,  and 
the  daily  increase  of  from  ten  to  twelve  pounds  in  the  weight  of 
the  body  in  some  cases  of  ascites,  in  which  the  amount  of  food 
taken  is  proportionally  small,  settle  this  question  beyond  a  doubt. 
As  a  general  rule,  whenever  absorption  becomes  very  active  in  any 
tissues  or  organs,  the  exhalations  and  secretions  become  so  in 
others,  and  vice  versa.  It  is  by  the  application  of  this  law  to  the 
treatment  of  disease,  that  the  physician  endeavors  to  promote  the 
absorption  of  fluid  collected  in  the  serous  membranes  by  increas- 
ing the  intestinal  urinary  or  cutaneous  secretions,  and  is  sometimes 
enabled  to  diminish  the  urinary  secretion  in  diabetes,  by  promot- 
ing profuse  perspiration. 

19* 


222  SYMPTOMS. 


SECTION    SEVENTH. 

• 
Symptoms  furnished  by  Nutrition. 

The  derangements  of  nutrition  in  disease  are  almost  infinite, 
but  in  most  cases  are  not  appreciable  by  the  senses  during  life,  and 
consequently  do  not  belong  to  symptomatology.  There  are  a  few, 
however,  properly  within  its  domain,  which  we  proceed  to  enu- 
merate. 

Nutrition  may  be  increased,  diminished  or  perverted.  It  can 
only  be  entirely  lost  in  those  parts  already  deprived  of  life. 

Increased  activity  of  nutrition  is  indicated  by  the  increased 
volume  of  all,  or  nearly  all,  the  constituent  parts  of  the  body,  but 
more  particularly  of  the  viscera  contained  in  the  chest  and  abdomen, 
of  the  muscles  and  of  the  adipose  tissue.  This  may  easily  be  con- 
founded with  the  obesity  produced  exclusively  by  an  accumulation 
of  fat  in  the  cellular  tissue.  The  latter  phenomenon,  though  rare, 
may  occur  in  disease  (page  76),  while  a  general  increase  of  vol- 
ume of  the  muscles  and  viscera,  is  never  a  symptom.  It  is  other- 
wise when  this  increase  is  partial :  such  is  that  of  which  the  heart 
and  liver  are  frequently  the  seat,  and  which  we  designate  by  the 
term  hypertrophy,  an  affection  rarely  simple,  and  nearly  always 
connected  with  some  obscure  modification  in  the  texture  of  these 
organs,  and  particularly  with  some  disturbance  in  their  functions, 
more  or  less  apparent. 

In  nearly  all  diseases  of  any  importance,  nutrition  becomes  lan- 
guid. This  is  apparent  from  the  emaciation  that  accompanies 
them.  When  this  languid  nutrition  exists  in  but  one  part  of  the 
body,  it  gives  rise  to  a  partial  emaciation  or  atrophy,  a  phenome- 
non particularly  owing  to  the  entire  inaction  of  organs,  or  to  a 
prolonged  compression  of  them.  It  is  also  of  frequent  occurrence 
in  the  muscles  of  limbs  under  the  influence  of  these  two  causes, 
and  necropsies  prove  that  the  internal  organs,  as,  for  example,  the 
lung  in  pleuritic  effusion,  may  also  become  the  seat  of  it  under 
the  influence  of  the  latter  cause. 

Atrophy  of  an  organ  may  also  follow  a  disorder  affecting  the 
circulation  or  innervation.  This  principle  has  been  ingeniously 
and  usefully  applied  to  the  treatment  of  certain  diseases.  Thus, 
Maunoir  of  Geneva,  and  Charles  Bell,  have  produced  the  atrophy 
of  a  voluminous  testicle,  by  a  ligature  round  the  spermatic  artery ; 
and  many  other  surgeons  have  arrested  the  progress,  and  brought 
about  the  decrease  of  considerable  tumors  in  the  face,  by  tying 
the  common  carotid  artery  on  the  corresponding  side.  The  liga- 
ture or  division  of  nerves  often  produces  atrophy,  also,  in  the 
muscles  to  which  they  are  distributed.  The  suspension  of  nervous 
action  appears,  also,  to  have  had  the  effect,  in  some  cases,  of  ar- 
resting the  development,  and  even  causing  the  atrophy,  of  certain 
morbid  tissues.  Dr.  Duparque  *  states  that  he  saw  an  ulcerated 

*  Maladies  de  V  Uterus. 


SYMPTOMS.  223 

cancer  of  the  breast  diminish  and  disappear,  in  consequence  of  a 
paralysis  affecting  the  side  of  the  body  corresponding  to  the  dis- 
eased part.  This  fact,  alone,  perhaps,  in  the  annals  of  science, 
requires  confirmation. 

Emaciation  should  not  be  confounded  with  leanness.  The  lat- 
ter is  that  condition  of  the  sound  or  diseased  body  in  which  there 
is  a  natural  thinness  of  flesh ;  while  the  former  is  that  state  in 
which  there  is  a  gradual  wasting  of  the  body.  An  emaciated  per- 
son may  still  have  embonpoint,  and  a  person  may  be  lean  who  is 
daily  gaining  flesh.  We  have  spoken  of  this  phenomenon  in  the 
article  devoted  to  the  exterior  of  the  body  (page  77),  and  do  not 
propose  to  recur  to  it  here. 

Nutrition  is  as  often  perverted  as  diminished.  It  is  to  this  per- 
version that  we  may  refer  all  the  organic  lesions  which  are  not  the 
result  of  an  external  cause :  the  production  of  cysts,  vicious  cur- 
vature of  the  bones,  the  various  degenerations  and  the  phlegmasiae 
themselves,  seem  to  be  originally  owing  to  a  modification  of  nu- 
trition. 

Nutrition  furnishes  another  class  of  phenomena  which  belong 
still  more  to  symptomatology.  We  refer  to  the  irregularities  of 
growth  in  the  growing  period  of  life.  The  growth,  which,  in 
health,  is  effected  in  different  individuals  according  to  a  variable 
progression,  but  always  within  certain  limits,  presents,  in  disease, 
many  remarkable  anomalies.  We  see  children  whose  growth 
seems  to  be  entirely  suspended  for  one,  and  even  for  many  years. 
This  phenomenon  is  not  uncommon  in  rachitis,  of  which  it  is 
sometimes  the  first  symptom.  We  have  seen  at  the  Clinical 
School  of  the  Hotel  Dieu,  a  person  fifteen  years  of  age,  affected 
with  diabetes,  whose  growth  had  been  suspended  since  he  was 
twelve  years  of  age,  the  period  at  which  the  diabetes  had  com- 
menced. We  see  a  greater  number  of  persons,  whose  length  of 
body  increases  one,  and  sometimes  several  inches  during  the  very 
limited  course  of  an  acute  disease.  These  two  opposite  phenom- 
ena are  equally  of  unfavorable  augury,  though  the  latter  indicates 
immediate  danger,  while  the  former  should  lead  us  to  fear  that  the 
development  of  the  body  is  permanently  arrested. 


ARTICLE    THIRD. 
Symptoms  furnished  by  the  Generative  Functions. 

THE  symptoms  of  which  we  have  hitherto  spoken  are,  almost 
without  exception,  common  to  the  two  sexes,  but  those  which  it 
remains  for  us  to  enumerate  are  peculiar  to  the  one  or  the  other. 
Having  already  pointed  out  the  principal  changes  that  disease 
produces  in  the  external  organs  of  generation,  in  the  section  de- 
voted to  the  consideration  of  the  exterior  of  body,  we  shall  now 
merely  say  a  few  words  upon  the  disorders  of  the  functions  de- 
signed for  the  reproduction  of  the  species.  We  shall  consider  them 
successively  in  man  and  woman. 


224  SYMPTOMS. 

A.  In  man,  the  secretion  of  semen  is  seldom  increased  in  disease. 
It  may  occur,  however,  in  erotic  melancholy,  and  is  one  of  the 
principal  symptoms  of  *  satyr  iasis  The  diminution,  or  almost  en- 
tire suspension,  of  this  secretion  is,  on  the  contrary,  of  frequent 
occurrence,  as  may  he  inferred  from  the  constant  flaccidity  of  the 
penis  and  the  absence  of  erection,  in  the  course  of  most  diseases. 

The  excretion  of  the  sernen  is  susceptible  of  different  disorders. 
It  is  attended  with  pain  in  the  phlegmasise  of  the  urethra.  With 
some  individuals  it  takes  place  when  the  penis  is  not  in  a  state  of 
erection,  particularly  during  the  efforts  attending  stools.  In  other 
cases,  the  emission  is  feeble,  or  interrupted  by  some  obstacle  (dis- 
permasici)*  and  the  seminal  fluid,  instead  of  being  excreted  in  jets, 
flows  slowly  through  the  orifice  of  the  urethra.  In  some  persons, 
emission  takes  place  upon  a  simple  touch,  and  before  the  introduc- 
tion of  the  penis  into  the  vagina.  Sometimes  there  is  a  deviation 
of  the  semen,  which,  after  being  forced  into  the  canal  of  the  ure- 
thra, flows  back  into  the  bladder  whence  it  is  excreted  mingled  with 
urine.  This  deviation  is  owing  to  the  wrong  direction  of  the 
ejaculatory  ducts  which  open  into  the  canal  of  the  urethra,  from 
before,  backward,  that  is,  contrary  to  the  natural  arrangement. 
It  sometimes  follows,  also,  stricture  of  the  urethra. 

Impotency,  or  inability  to  effect  the  venereal  act,  may  arise  from 
a  multitude  of  different  causes,  the  consideration  of  which  would 
be  irrelevant  in  this  connection.  We  will  merely  remark,  after  re- 
ferring to  the  influence  of  imagination  upon  this  phenomenon,  that 
sometimes  the  penis  is  not  capable  of  erection,  and  sometimes 
emission  does  not  take  place,  at  least  at  the  proper  time.  The  loss 
of  power  of  erection  is,  in  a  certain  number  of  cases,  the  first,  or 
one  of  the  first  symptoms  of  a  disease  of  the  nervous  centres,  and 
particularly  the  spinal  marrow. 

We  observe,  in  some  cases  of  disease,  frequent  and  even  habit- 
ual erections,  taking  place  independently  of  the  natural  causes 
that  excite  them.  This  phenomenon  occurs,  particularly,  in  cases 
of  vesical  calculi,  and  in  certain  chronic  eruptions  of  the  skin. 
The  application  of  a  blister  will  produce  it  in  some  persons. 

B.  In  woman,  the  functions  of  reproduction  present  a  greater 
number  of  symptoms.  The  menses,  the  lochia,  and  the  secretion 
of  milk  deserve  particular  attention. 

In  some  young  females  the  catamenia  do  not  appear  at  the 
usual  age.  This  delay  may  be  owing  to  the  general  state  of  the 
constitution,  or  be  connected  with  the  condition  of  the  uterus  or  its 
appendages.  In  most  cases,  however,  it  is  referable  to  disease  in 
a  remote  organ,  and  particularly  the  lungs. 

The  menstrual  flux  is  sometimes  increased  in  disease.  This  in- 
crease, when  very  considerable,  constitutes  menorrhagia,  and  may 
take  place  at  the  usual  menstrual  periods,  or  in  their  intervals. 
When  the  blood  escapes  in  clots,  it  is  always  important  to  examine 

*  Jvg,  with  difficulty  ;  ani^a,  semen. 


SYMPTOMS.  225 

it  with  care,  in  order  to  ascertain  whether  it  contains  a  foetus  or  its 
membranes,  particularly  when  the  flow  of  blood  is  accompanied  with 
expulsory  pains  analogous  to  those  of  parturition.  Metrorrhagia 
is  often  symptomatic  of  abortion  either  in  progress  or  already  effect- 
ed, and  is  sometimes  connected  with  disease  of  the  uterus,  such  as 
polypus,  fibrous  tumor,  cancers,  granulated  metritis,  etc.  Metror- 
rhagias,  or  morbid  haemorrhages  of  the  uterus,  sometimes  occur 
spontaneously  in  the  course  of  acute  diseases,  particularly  dur- 
ing eruptive  fevers  and  variola,  and  give  a  graver  character  to 
prognosis.  In  all  these  cases  an  examination  of  the  uterus  by  the 
touch  is  indispensable.  The  diminution  of  the  periodical  flux  is 
much  more  frequent,  occurring  in  most  chronic  affections.  In 
their  last  stage  it  is  almost  always  suspended.  Deviations  of  the 
menstrual  flux  have  also  been  very  frequently  observed,  and  may 
take  place  through  a  great  number  of  different  passages,  but  par- 
ticularly through  one  of  the  mucous  membranes  or  the  skin. 

The  flow  of  lochia  after  parturition,  may  be  unusually  great; 
more  frequently,  however,  if  any  disease  exist  at  this  period,  this 
discharge  is  much  diminished  in  quantity,  and  sometimes  even 
entirely  suppressed,  as  in  puerperal  peritonitis. 

The  volume  of  the  mammae  is  increased  during  pregnancy. 
This  phenomenon  occurs,  also,  but  rarely,  in  certain  affections  of 
the  uterus.  There  are  a  great  number  of  females  whose  menstrual 
periods  are  preceded  and  accompanied  by  a  perceptible  tumefac- 
tion of  the  mammae,  while  at  the  same  time  they  become  the  seat 
of  a  sensibility  more  or  less  acute.  It  is  particularly,  however,  a 
few  days  after  parturition  that  the  mammae  present  a  great  in- 
crease of  volume,  at  the  time  that  the  secretion  of  milk  is  effected. 
The  absence  of  tumefaction  of  the  mammae  or  their  sudden  falling 
away,  under  such  circumstances,  is  always  a  suspicious  phenome- 
non. The  mammae  diminish  in  volume,  and  sometimes  become 
actually  atrophied,  in  women  advanced  in  years. 

The  secretion  of  the  milk  never  increases  during  the  progress  of 
disease,  but  nearly  always  diminishes,  and  is  sometimes  suppress- 
ed. This  suppression  is  generally  accompanied  by  shrinking  of 
the  mammse,  and  sometimes  by  their  induration,  a  phenomenon 
attributed  by  some  authors  to  the  coagulation  of  the  milk  in  the 
mammary  gland. — The  microscopic  examination  of  the  milk  is  not 
without  interest  in  a  pathological  point  of  view.  By  means  of  this 
examination,  the  milk  has  sometimes  been  found  to  be  mingled 
with  small  quantities  of  pus. — With  regard  to  deviations  of  the 
milk,  of  which  so  much  has  been  said,  and  which  was  once  thought 
to  have  been  proved  by  the  milky  appearance  of  pus  in  abscesses, 
of  leucorrhaeal  mucus,  or  of  the  fluid  furnished  by  the  inflamed 
pleura  or  peritoneum,  they  are  no  longer  believed  to  take  place, 
and  consequently  need  not  here  be  discussed.  The  facts,  that  we 
find  this  lactiform  matter  in  men  as  well  as  women,  and  that  if  it 
present  the  color  of  milk,  it  has  none  of  its  properties,  are  sufficient 
to  overthrow  the  hypothesis  if  it  still  has  any  advocates.  Women 
are  also  accustomed  to  attribute  the  fixed  or  undefined  pains,  and 


226  SYMPTOMS. 

the  cutaneous  eruptions  that  follow  delivery,  to  the  presence  of 
milk  in  the  economy.  They  designate  these  symptoms,  whatever 
they  may  be,  by  the  term  diffused  milk.  This  second  species  of 
deviation  is  a  mere  unfounded  hypothesis. 

Barrenness  may  follow  more  various  causes  than  those  that  give 
rise  to  impotency  in  man.  The  most  common,  are  vicious  confor- 
mation or  position  of  the  os  uteri,  the  obliteration  of  the  fallopian 
tubes,  the  various  lesions  of  the  ovaries,  and  the  presence  of  polypi 
in  the  neck  of  the  uterus. 

We  may  also  refer  to  this  head  of  disorders  furnished  by  the 
generative  functions  of  women,  the  facility  with  which  abortion  is 
effected  in  some,  and  the  inability  of  others  to  carry  the  product  of 
conception  during  the  natural  period  of  pregnancy. 

In  both  sexes  the  venereal  desire  (appetitus  venerens)  may  be 
increased,  diminished  or  perverted.  It  is  increased  in  satyriasis 
and  nymphomania,  and  in  some  cases  of  erotic  melancholy.  It  is 
diminished  in  most  diseases,  and  particularly  in  leucorrhea  in 
women,  and  in  both  sexes  in  persons  addicted  to  masturbation. 
Its  entire  loss  is  designated  by  the  term  anaphrodisia  (anaphrodi- 
sia.*) It  is  perverted  in  certain  cases  of  mania,  and  some  other 
neuroses,  in  which  the  patient  is  incessantly  addicted  to  masturba- 
tion, or  is  led  to  the  commission  of  unnatural  acts. 

Such  are  the  principal  symptoms  furnished  by  the  generative 
functions.  To  these  we  may  add  those  that  are  discovered  by 
touch  and  the  speculum  uteri,  of  which  we  shall  give  a  summary 
in  the  chapter  on  diagnosis. 


ARTICLE  FOURTH. 

Symptoms  considered  in  Disease. 

HAVING  thus  far  treated  of  symptoms  in  the  abstract,  we  shall 
now  proceed  to  consider  them  in  connection  with  disease,  of  which 
they  constitute  the  elements. 

Sometimes  but  one  symptom  makes  its  appearance  ;  as  in  cases 
of  vomiting,  deafness  or  epistaxis ;  but  generally  many  occur 
simultaneously.  These  symptoms  are  grouped  in  a  thousand 
ways,  and  by  their  various  combinations,  constitute  the  phenome- 
nal part,  or  the  apparent  features  of  a  disease  :  they  lead  to  the 
knowledge  of  internal  lesions  when  these  exist,  and  are  of  the 
highest  importance,  in  all  cases,  in  enabling  us  to  decide  upon  the 
nature  of  the  disease  with  which  the  patient  is  affected.  The 
symptoms  which  appear  simultaneously  in  the  same  patient,  are 
often  in  intimate  connection  with  each  other ;  they  are  not  all  of 
equal  importance,  either  in  relation  to  the  diagnosis  of  the  disease 
or  the  influence  they  may  exert  upon  its  progress ;  lastly,  they  do 

*  A  privative,  aipgoSioia,  pleasure. 


SYMPTOMS. 

not  all  appear  at  the  same  time.     We  shall  now  briefly  consider 
them  in  these  different  points  of  view. 

$  I.  It  is  highly  important  in  the  appreciation  of  symptoms,  to 
be  able  in  a  case  of  general  functional  disorder,  to  distinguish 
which  function  was  primarily  affected,  and  not  to  confound  symp- 
toms which  may  be  called  primary ',  or  local,  with  their  accompany- 
ing secondary,  or  general,  phenomena.  In  pleurisy,  for  example, 
there  may  be  observed  simultaneously,  redness  of  the  face,  pain 
in  the  chest,  feebleness  or  disorder  of  the  intellectual  functions, 
thirst,  interrupted  voice,  cough,  dyspnoea,  frequency  of  the  pulse, 
increased  heat,  high  colored  urine,  and  many  other  symptoms 
which  may  accompany  the  disease  during  the  whole,  or  a  part,  of 
its  duration.  The  importance  of  isolating  the  primary,  from  the 
secondary,  phenomena,  is  here  evident.  The  first,  are  pain  in  the 
side,  dyspnoea,  and  cough,  to  which  may  be  added  the  difficulty 
of  speech  ;  the  second,  are  the  color  of  the  face,  headache,  frequency 
of  the  pulse,  heat,  disordered  secretions,  &c.  The  sensible  changes 
presented  by  the  inflamed  pleura  explain  all  the  primary  phenom- 
ena, as  the  pain,  dyspnoea  and  cough.  The  connection  between 
the  symptoms  and  this  disease  may  be  also  easily  explained.  The 
pleuritic  pain,  and  probably  also  the  inflamed  state  of  the  pleura, 
oblige  the  patient  to  take  short  and  frequent  inspirations ;  respira- 
tion is  so  intimately  connected  with  the  circulation,  that  when  one 
is  accelerated  the  other  necessarily  becomes  so.  The  frequency 
of  these  two  functions  causes  elevation  of  heat,  in  the  production 
of  which  both  appear  to  concur ;  the  increased  heat  augments  the 
thirst,  and  renders  the  urine  more  highly  charged. 

But  it  is  impossible,  in  most  cases,  to  discover  the  connection 
between  the  various  symptoms,  and  we  are  compelled  to  attribute 
them  to  the  invisible  bond  of  sympathy.  The  relations  between 
all  parts  of  the  body  in  health  as  well  as  disease  are  so  intimate, 
that  no  one  can  become  gravely  affected  in  its  structure  or  func- 
tions, without  all  the  others,  or  at  least  many  of  them,  participa- 
ting in  some  degree.  Sympathetic  phenomena,  are  those  which 
arise  from  this  connection  alone  between  the  different  organs,  un- 
accompanied by  any  primary  lesion  of  the  part  which  is  their 
seat,  and  sympathy  *  is  the  term  applied  to  the  organic  condition 
which  presides  over  the  production  of  these  phenomena.  This 
produces,  in  disease,  effects  more  various  and  extraordinary  than 
in  health.  Without  here  speaking  of  that  universal  or  general 
sympathy,  by  virtue  of  which  the  whole  economy  participates  in 
the  disorder  of  some  organ  or  function,  as  is  observed  in  the  in- 
flammation of  a  viscus  or  any  other  internal  disease,  let  us  con- 
sider for  a  moment  the  phenomena  which  depend  upon  special  or 
particular  sympathy,  or  that  which  exclusively  exists  between 
certain  organs. 

Hunter  divided  these  numerous  and  various  phenomena  into 

*  2vrt  with, at  the  same  time;  rta&og,  affection. 


228  SYMPTOMS. 

three  series,  according  to  their  appearance  in  organs  which  are 
continuous,  contiguous  or  remote  ;  this  division  is  more  simple  and 
natural  than  those  since  established.  To  the  sympathy  of  con- 
tinuity, may  be  referred  the  pain  felt  in  the  whole  track  of  a  nerve 
when  any  part  of  it  is  irritated  or  contused ;  the  general  convul- 
sions and  tetanus  following  laceration  of  a  nervous  filament ;  the 
itching  of  the  nasal  fossae  in  persons  affected  with  intestinal  worms, 
and  pain  in  the  glans  penis  in  those  affected  with  calculus  in  the 
bladder.  The  sympathy  of  contiguity  produces  vomiting  in  perito- 
nitis, dysuria  in  haemorrhoidal  swelling,  dysentery,  &c.  Remote 
sympathy  sometimes  affects  similar  organs,  or  those  associated  in 
the  performance  of  the  same  function,  and,  sometimes,  parts  be- 
tween which  no  relation  exists.  In  complete  amaurosis  of  one 
side,  the  oscillations  of  the  iris  are  sometimes  observed  to  be  trans- 
mitted from  the  sound  eye  to  that  which  is  incapable  of  distinguish- 
ing the  light,  and,  when  one  of  these  organs  is  inflamed,  the  other 
cannot  endure  the  light.  These  various  phenomena  are  attributa- 
ble to  the  similarity  in  the  structure  and  functions  of  the  affected 
organs.  The  relation  existing  between  the  mammae  and  uterus, 
and  between  the  expiratory  muscles  arid  lungs,  seem  to  account, 
to  a  certain  extent,  for  the  shrinking  or  swelling  of  the  mammae  in 
certain  affections  of  the  uterus,  and  the  involuntary  cough  excited 
by  the  accumulation  of  mucus  in  the  trachea.  The  examples  of 
remote  sympathy  between  two  organs  which  do  not  concur  to  the 
performance  of  the  same  functions,  are  very  numerous,  and  can- 
not be  explained  by  nervous  anastomoses,  although  many  physi- 
cians have  thus  endeavored  to  account  for  it  in  some  sympathetic 
phenomena  of  this  kind,  and  particularly  in  the  pain  of  the  right 
shoulder,  sometimes  accompanying  inflammation  of  the  liver. 
The  cough  sometimes  observed  in  certain  affections  of  the  stom- 
ach, liver  and  uterus ;  the  vomiting  which  occurs  in  diseases  of 
the  brain,  lungs,  kidneys  and  uterus ;  the  trembling  of  the  lower 
lip  and  ptyalism  which  often  precede  vomiting,  dilatation  of  the 
pupils  in  verminous  affections,  and  pain  in  the  knee  in  hip  disease, 
are  all  sympathetic  phenomena,  most  of  which  have  been  noticed, 
but  which  are  entirely  inexplicable. 

Such  are  the  principal  effects  of  morbid  sympathy,  which,  as 
has  been  said,  transmits  throughout  the  economy  the  irradiations 
of  the  affected  organ. 

$  II.  The  symptoms  which  appear  simultaneously  in  the  course 
of  any  disease,  are  not  all  of  equal  importance.  There  are  those 
which  are  principal  or  characteristic,  and  others,  that  are  called 
accessory. 

When  all  the  functions  of  the  economy  are  simultaneously  de- 
ranged, many  of  them  severely,  no  organ  being  more  particularly 
affected  than  the  others,  the  most  apparent  phenomena  become  the 
principal  symptoms,  the  others  being  only  accessory  :  this  is  par- 
ticularly observed  in  malignant  intermittent  fevers.  In  those 
diseases,  on  the  contrary,  in  which  a  single  organ  is  the  seat  of  the 


SYMPTOMS.  229 

affection,  the  importance  of  the  symptoms  is  not  determined  by 
their  intensity,  but  by  their  seat  and  the  function  which  is  de- 
ranged. Thus  in  peripneumony,  a  slight  pain  in  one  side  and  a 
few  rusty  colored  sputa  are  the  principal  symptoms ;  while  the 
violent  headache,  high  colored  urine,  and  high  fever,  are  but  ac- 
cessory phenomena. 

$  III.  Symptoms  have  been  also  divided  into  active  and  passive. 

In  defining  disease  to  be  a  struggle  of  nature,  in  which  she  is 
endeavoring  to  repel  or  destroy  the  morbid  cause,  it  seems  to  be 
forgotten  that,  in  some  affections,  no  sign  of  salutary  reaction  can 
be  perceived,  and  that  most  of  the  symptoms  tend,  on  the  con- 
trary, to  hasten  the  fatal  result.  Thus  in  pulmonary  phthisis,  the 
night  sweats,  diarrhoea,  cough  and  haemoptysis,  daily  aggravate 
the  condition  of  the  patient.  But  there  are,  also,  other  affections 
in  which  no  favorable  reaction  can  be  discovered.  The  peculiar 
phenomena  developed  around  a  thorn  imbedded  in  the  skin,  the 
fever  which  accompanies  the  inflammation  of  this  membrane  and 
the  subjacent  parts,  the  suppuration  which  occurs  around  the  for- 
eign body,  and  causes  its  expulsion  after  having  produced  absorp- 
tion of  the  integuments  in  the  part  corresponding  to  the  abscess, 
or  destroyed  the  edges  of  the  opening  which  gave  exit  to  the 
material  agent  of  the  disease,  are  symptoms  which  we  may,  with 
some  modern  authors,  term  active. 

In  many  acute  diseases,  most  of  the  symptoms  seem  also  to 
indicate,  if  not  a  concurrence  of  all  the  forces  of  the  economy 
against  the  morbific  cause,  at  least  an  evident  struggle  between 
them.  But  it  must  be  admitted  that,  in  most  cases,  the  distinction 
into  active  and  passive  symptoms  is  utterly  impossible. 

$  IV.  All  the  symptoms  do  not  make  their  appearance  at  the 
commencement  of  diseases.  In  those  whose  course  is  rapid, 
the  principal  and  characteristic  symptoms  are  generally  developed 
about  the  second  or  third  day;  in  those  which  progress  slowly, 
they  may  not  appear  for  several  months,  and  sometimes  many 
years.  In  both  cases,  various  accidental  symptoms,  called  epi- 
phenomena,  *  occur  in  the  course  of  the  affection,  which  differ 
from  symptoms,  properly  so  called,  in  not  being  as  intimately  con- 
nected with  the  existence  of  the  disease.  To  the  epiphenomena, 
or  accidents,  may  be  referred  the  supervenientia,  the  epigenemata, 
and,  what  have  been  styled  in  the  schools,  the  symptoms  of  the 
cause,  and  the  symptoms  of  the  symptom.  The  supervenientia 
are  phenomena  foreign  to  the  disease,  but  developed  by  it ;  as  the 
appearance  of  the  menstrual  flux  before  the  ordinary  period ;  the 
pains  of  dentition  occurring  in  children,  but  which  were  not  ex- 
perienced previous  to  the  existing  disease ;  and  finally,  the  prodi- 
gious multitude  of  parasitic  animals,  worms,  and  particularly  lice, 
observed  in  some  patients.  The  epigenomata  are  accidents  mani- 

*"Em,  upon  j  ycmojuat,  I  appear. 

20 


230  PROGRESS    OF    DISEASES. 

fested  during  the  disease,  but  which  depend  upon  some  external 
cause,  as  the  negligence  of  the  assistants,  or  imprudence  of  the  pa- 
tients themselves.  The  symptoms  of  the  cause  are  accidental  phe- 
nomena which  seem  to  depend,  riot  upon  the  disease,  which  does  not 
ordinarily  produce  them,  but  upon  the  determining  cause  of  the 
disease  itself ;  as  in  the  case  of  haemoptysis  occurring  in  the  course 
of  an  inflammatory  fever.  As  this  symptom  does  not  ordinarily 
accompany  this  disease,  it  has  been  considered  rather  the  result  of 
the  phlethora  which  produces  the  fever,  than  of  the  fever  itself. 
Finally,  should  this  haemorrhage  become  sufficient  to  cause  fainting, 
the  latter  would  be  considered,  in  the  language  of  the  schools,  the 
symptom  of  a  symptom.  These  distinctions  have  been  justly 
abandoned,  and  their  distinctive  appellations  have  become  to  us 
almost  unintelligible.  The  various  accidents  which  may  be  added 
to  the  symptoms  of  disease  may,  withoutin  convenience,  be  classed 
under  the  head  of  epiphenomena. 

Such  are  the  principal  points  of  view  in  which  symptoms  may 
be  considered.  In  the  chapter  on  diagnosis,  we  shall  consider 
their  semeio'logical  value.  —  O. 


CHAPTER   VIII. 

PROGRESS    OR    COURSE    OF   DISEASES. 

THE  progress  of  diseases  (morborum  decnrsus)  may  be  denned 
to  be  the  mode  of  production  and  succession  of  the  material  lesions 
and  symptoms  which  characterize  them. 

The  alterations  occurring  in  the  texture  of  organs  during  disease, 
elude,  in  many  cases,  our  means  of  observation.  There  is,  how- 
ever, pa  considerable  number  of  diseases  in  which  we  can,  to  a 
certain  extent,  trace  the  internal  modifications  and  most  apparent 
functional  derangements.  Without  mentioning,  in  this  place,  those 
diseases  whose  seat  is  the  cutaneous  surface,  or  those  occupying 
the  orifices  of  the  mucous  membranes,  or  parts  so  near  to  these 
orifices,  that  the  eye  can  observe  and  follow  through  their  various 
phases,  the  changes  which  occur  in  their  material  disposition  ; 
there  are  certain  other  affections,  as  pleurisy,  pneumonia  and 
scirrhus  of  the  stomach,  in  which,  by  the  aid  of  all  our  explorative 
means,  we  are  able  to  recognise  the  commencement,  progress  and 
diminution  of  a  pleuritic  effusion,  the  progressive  conversion  of 
pulmonary  engorgement  into  hepatization,  the  extension  of  the 
disease  from  the  point  primarily  affected,  to  other  portions  of  the 
same  organ,  and  the  gradual  increas'e  of  a  tumor  developed  in  the 
greater  curvature  of  the  stomach.  But  it  should  be  recollected 
that  material  organic  lesions  are  in  most  cases  appreciable  only 
after  death ;  and  in  many  instances,  it  is  almost  wholly  by  the 


PROGRESS    OF    DISEASES.  231 

alterations  which  supervene  in  the  symptoms,  that  the  physician 
can  trace  and  study  the  progress  of  diseases,  in  which  are  com- 
prehended their  type,  their  form,  either  acute  or  chronic,  the  dis- 
tinction of  their  periods,  and  the  examination  of  the  numerous 
circumstances  which  influence  them. 

§  I.  The  type  -  (typus)  is  the  order  in  which  the  symptoms 
become  aggravated  or  reproduced. 

It  is  continued  (  T.  continuus)  when  the  symptoms  persist  unin- 
terruptedly from  the  commencement  to  the  termination  of  the 
disease;  periodical  or  intermittent  (T.  periodicus,  inter 'mittens) , 
when  they  appear  and  disappear  at  intervals. 

A.  A  disease  of  continued  type  is  sometimes  equally  intense 
throughout  its  course :  it  is  then  called  continent  (morbus  conti- 
nens)  ;  such  is,  in  certain  cases,  the  ephemeral  inflammatory  fever, 
exhibiting,  during  its  short  continuance,  variations  so  slight  as  not 
to  deserve  notice ;  no  acute  disease  would  be  continent,  if  this 
term  be   employed    in   a    strict  sense.     The  continued   diseases 
are   not   usually  of  uniform   intensity;  they  have   exacerbations 
alternating  with  the  decrease  of  the  symptoms  or  remission.     The 
exacerbation,  paroxysm  or  access,  consists  in  a  more  or  less  marked 
increase  of  one,  many,  or  all  of  the  symptoms  belonging  to  the 
disease  ;  the  remission,  in  the  opposite  change. 

There  are  certain  continued  affections,  whose  symptoms,  instead 
of  presenting  these  opposite  alternations,  increase  regularly  in  in- 
tensity from  the  attack  to  the  termination ;  there  are  others,  on  the 
contrary,  which  exhibit  their  greatest  intensity  at  their  commence- 
ment, and  become  gradually  less  serious.  The  fever  which  pre- 
cedes the  appearance  of  the  catamenia,  often  exhibits  an  increasing 
intensity ;  the  contrary  has  been  observed  in  regard  to  ephemeral 
fever. 

B.  Periodical  or  intermittent  diseases   assume   very  various 
forms,  either  in  regard  to  the  actual  paroxysms*  (accessus),  (such 
is  the  name  given  to  the  reappearance  of  the  symptoms)  or  to  the 
interval  between  them.     Certain  paroxysms  present,  in  the  midst 
of  variable  symptoms,  a  chill,  succeeded  by  heat  and  perspiration; 
others,  which  are  also  called  attacks,  do  not  exhibit  these  phenom- 
ena.    The  first  are  peculiar  to  intermittent  fever ;  the  latter  are 
common  to  all  other  periodical  diseases,  such  as  epilepsy,  hysteria 
and  many  nervous  affections.     The  interval  between  the  febrile 
paroxysms  is  called  apyrexia-\  or  intermission  (apyrexia,  inter- 
missio)-,  the  intermediate  periods  of  the  attacks  have  received  no 
particular  appellation. 

The  intermittent  or  periodical  type  may  present  itself  under 
various  forms :  the  principal  are  the  quotidian  (quotidianus),  ter- 

*  TTaQo^vrtunc,  oi/'e,  acute  j  rtaqa,  beyond, 
t  A  privative,  ifv^f^o;,  fever. 


232  PROGRESS    OF    DISEASES. 

tian  (tertianus),  and  quartan  (quartanus).  In  the  first,  the  par- 
oxysms occur  every  day,  and  resemble  each  other  in  duration, 
violence  and  principal  symptoms;  in  the  second,  the  paroxysms 
occur  every  second  day;  in  the  quartan  type,  every  third  day. 
A  type  presenting  recurrences  every  fifth,  and  one  every  sixth 
day,  have  been  admitted  ;  but  they  have  been  very  rarely  ob- 
served, and  many  practitioners  have  thought  that  the  reappear- 
ance of  certain  fevers  with  these  unusual  types  should  be  consid- 
ered accidental.  The  existence  of  monthly  or  annual  intermittent 
fever  is  not  now  admitted.  When  an  intermittent  disease  reap- 
pears at  irregular  intervals,  it  is  erratic  or  atypic  (morbus  erra- 
ticus). 

The  quotidian,  tertian,  and  quartan  types  present  numerous 
varieties :  1.  In  the  double  quotidian  (quotidianus  duplex),  two 
paroxysms  occur  every  day.  2.  In  the  double  tertian  (tertianus 
duplex} ,  there  is  a  paroxysm  every  day,  those  of  alternate  days 
corresponding ;  the  third  resembling  the  first,  the  fourth  the  second. 
3.  In  the  duplicated  tertian  (tertianus  duplicatus),  there  are  two  par- 
oxysms on  the  same  day  and  one  day  of  apyrexia.  4.  If  the  type 
be  triple  tertian  (tertianus  triplex),  there  are  two  paroxysms  on 
the  first  and  on  the  third  day,  and  one  only  on  the  second  and 
fourth ;  these  paroxysms  correspond  every  second  day.  5.  The 
double  quartan  type  (quartanus  duplex)  has  one  paroxysm  on  two 
successive  days ;  the  paroxysm  of  the  fourth  day  is  similar  to  that 
of  the  first,  that  of  the  fifth  to  that  of  the  second,  the  apyrexia  of 
the  sixth  day  corresponds  to  that  of  the  third.  6.  In  the  duplicated 
quartan  (quartanus  duplicatus),  there  are  two  paroxysms  on  the 
same  day,  occurring  every  third  day.  7.  In  the  triple  quartan 
(quartanus  triplex),  there  is  a  paroxysm  each  day,  as  in  the  quo- 
tidian and  double  tertian;  but  in  the  triple  quartan,  the  paroxysms 
correspond  as  to  the  hour,  duration  and  severity,  on  each  third 
day ;  the  first  three  differ  from  each  other,  the  fourth  resembles 
the  first,  the  fifth  the  second,  the  sixth  the  third;  in  the  double 
tertian  type,  the  paroxysm  is  different  every  other  day,  and  corres- 
ponds every  second  day ;  in  the  quotidian  there  is  constant  simi- 
larity of  access.  Of  all  these  varieties  of  intermittent  types,  the 
double  tertian  is  the  only  one  frequently  met  with :  all  the  others 
may  be  considered  exceptional. 

C.  Diseases,  and  fevers  in  particular,  occasionally  run  an  inter- 
mediate course  between  the  continued  and  intermittent  types;  this 
is  called  the  rerinittent  type  (remittens).  Like  the  intermittent,  it 
presents  paroxysms  of  rigor,  heat  and  sweating  ;  and  like  the  con- 
tinued type,  certain  symptoms  which  persist  uninterruptedly 
throughout  the  disease.  Such  is  the  exact  definition  given  by 
Pinelof  the  term  remittent ;  for,  before  his  time,  physicians  con- 
founded under  this  title,  continued  fever  with  exacerbations  and 
remittent  fevers  properly  so  called. 

The  cause  of  the  periodicity  of  diseases  is  one  of  the  most  ob- 
scure points  in  general  pathology.  We  consider  it  quite  natural 


PROGRESS    OF   DISEASES.  233 

that  phlogosis,  degeneration,  or  any  other  organic  alteration,  should 
produce  phenomena  which  continue  without  interruption,  as  does 
their  determining  cause.  But  it  is  quite  otherwise  with  diseases 
which  disappear  and  return  at  intervals,  particularly  if  their  re- 
turn be  regular.  If  we  suppose  the  existence  of  a  material  lesion, 
how  does  it  happen  that  its  action  is  only  transient  ?  If  functional 
derangement,  unaccompanied  by  organic  lesion,  be  assumed,  we 
admit  an  effect  without  a  cause.  Many  physicians  have  endeav- 
ored to  explain  a  phenomenon  whose  conception  even,  presents 
such  difficulty.  The  majority  have  concluded  that  the  productive 
cause  of  the  intermittent  or  periodical  type  ought  to  cease,  at  any 
rate,  partially,  by  the  very  effect  of  the  paroxysm ;  but  that  this 
cause,  engendered  within,  or  introduced  into  the  system,  confined 
to  one  point  or  disseminated  through  the  whole  body,  was  after- 
ward reproduced  with  more  or  less  promptitude,  so  as  to  excite  a 
fresh  paroxysm.  The  cause  has,  by  some,  been  attributed  to  cer- 
tain fluids  of  the  economy,  as  the  mucus,  the  bile  or  the  blood ; 
by  others,  to  the  nervous  system ;  by  others  still,  to  fermentation 
or  remarkable  disturbance,  or  to  obstruction  of  the  circulation  in 
any  part  of  the  body,  the  vena  porta,  for  instance ;  by  another 
class,  it  has  been  assigned  to  the  sensitive  principle;  and  lastly, 
some  ascribe  it  to  irritation  or  intermittent  phlegmasia. 

These  and  all  other  explanations  are  pure  hypotheses,  unsup- 
ported by  sound  reasons,  and  the  majority  of  which  are  in  opposition 
to  facts.  The  periodicity  of  diseases  is  well  known,  but  inexplica- 
ble. We  recognise  it,  moreover,  in  a  multitude  of  phenomena  both 
out  of  the  system  and  within  it,  and  in  no  way  can  it  be  explained. 
The  ebb  and  flow  of  the  sea,  the  sleep  of  vegetables  and  animals, 
the  regularity  of  the  menstrual  and  hsemorrhoidal  discharges,  are 
each  phenomena  whose  periodicity  is  as  difficult  of  explanation  as 
that  of  diseases.  This,  then,  should  rather  be  attributed  to  the 
weakness  of  human  understanding  than  to  the  imperfection  of  the 
science. 

$  II.  Diseases  have  been  divided  by  authors  into  acute  and 
chronic,  chiefly  from  their  duration.  We  think,  however,  that 
there  is  a  certain  number  which  are  acute  in  their  course,  although 
by  their  duration  they  belong  to  the  chronic  diseases  ;  as  also  there 
are  others,  chronic  in  their  course,  but  acute  in  duration.  A  dis- 
ease is  acute  in  its  progress  when  the  development,  succession,  and 
intensity  of  its  characteristic  symptoms  announce  an  affection 
necessarily  of  short  duration;  on  the  contrary,  when  the  symptoms 
appear,  increase  and  succeed  one  another  slowly,  its  course  is 
essentially  chronic.  A  typhoid  fever  which  passes  the  fortieth  and 
even  the  sixtieth  day,  is  still  an  acute  disease;  a  tubercular  affec- 
tion is  a  chronic  disease,  although  it  prove  fatal  in  a  shorter  time. 

$  III.  All  authors  have  divided  disease  into  a  certain  number  of 
periods  •  *  this  is  the  name  applied  to  each  of  its  successive  phases. 

*  HtQtudog,  circuit}  otfoj,  path  j  7it(u,  around. 

20* 


234  PROGRESS    OF    DISEASES. 

The  number  of  periods  in  disease  has  not  been  determined ;  the 
majority  of  authors  recognise  four  or  five ;  others  have  enumerated 
even  eight  in  certain  affections.  With  M.  L.  Beauvais,  we  shall 
admit  three  only,  each  distinguished  by  an  important  and  last- 
ing condition,  as  the  increase,  persistence  and  diminution  of  the 
symptoms,  and  we  shall  name  them,  according  to  universal  usage, 
period  of  increase  or  progress,  static,  and  declining  periods.  The 
invasion  of  the  disease,  being  only  its  commencement,  should  not 
be  considered  as  a  period ;  if  it  be,  the  moment  of  its  cessation 
should  be  made  one  also. 

A.  The  first  period,  that  of  increase,  progress  (incrementum), 
extends  from  the  invasion  to  the  highest  degree  of  intensity  mani- 
fested by  the  symptoms. 

The  invasion  OY  first  appearance  (invasio,  initiummorbi),  is  the 
moment  at  which  the  disease  commences.  It  is  never,  or  very 
rarely,  appreciable  in  chronic  affections,  and  generally  is  recognised 
with  certainty  in  acute  diseases  alone;  and  even  in  them,  is  fre- 
quently so  indistinct  that  it  is  difficult,  or  even  impossible,  to  sepa- 
rate it  from  the  time  immediately  preceding  or  following.  This  is 
the  case  whenever  the  intensity  of  the  precursory  phenomena  in- 
creases gradually,  so  as  to  lead  the  system  by  degrees  from  a  state 
of  health  to  disease  ;  or  when  an  affection  becomes  manifest  under 
certain  natural  conditions  which  have  materially  modified  the 
functions,  as  for  example,  after  parturition.  Sometimes,  it  is  true, 
rigor,  syncope  or  some  other  remarkable  phenomenon  supervenes 
at  such  a  time,  which  may  be  considered  indicative  of  commencing 
disease ;  but  uncertainty  often  exists. 

The  invasion  of  acute  diseases,  and  especially  those  of  a  grave 
nature,  is  usually  announced  by  a  chill,  of  variable  duration  and 
severity ;  this  is  succeeded  by  heat,  and  alternates  with  it  tor  an  in- 
definite period  manifesting  itself  at  one  time  suddenly,  in  persons 
previously  healthy,  at  another,  after  several  days  of  indisposition ; 
in  most  cases  the  patient  is  obliged  to  take  his  bed. 

Invasion  is  accompanied  by  certain  other  phenomena  ;  such  are, 
a  remarkable  alteration  of  the  countenance,  tremor,  convulsions, 
syncope,  fixed  pain  in  a  particular  organ,  delirium,  retching,  vo- 
miting, dyspnoea,  accelerated  pulse,  haemorrhage,  etc. 

The  invasion  of  most  diseases  may  happen  at  any  hour  of  day 
or  night ;  there  are  some  which  commence  more  particularly  at 
certain  hours.  For  example,  paroxysms  of  asthma  occur  most 
frequently  in  the  night ;  those  of  intermittent  fever,  of  the  quoti- 
dian type,  in  the  morning;  those  of  the  tertian  type,  towards 
noon ;  of  the  quartan,  in  the  latter  part  of  the  day ;  of  symptom- 
atic intermittent  fever,  in  the  evening.  This  fact  explains  the  ob- 
servation of  many  physicians,  that  intermittent  fevers,  whose 
paroxysms  recur  constantly  at  evening,  usually  resist  the  curative 
action  of  quinine ;  this  remedy  not  acting  in  full  force,  except  in 
cases  of  essential  intermittents. 

The  phenomena  which  announce  the  invasion  of  a  disease  are 


PROGRESS    OF    DISEASES.  235 

occasionally  characteristic  of  it ;  they  then  persist  through  its  sub- 
sequent stages ;  but,  most  frequently,  they  cease  from  the  first  day, 
(as  the  chill  which  is  common  to  all  the  acute  affections,)  and  are 
replaced  by  others. 

The  first  period  assumes  various  forms  in  different  diseases.  In 
those  of  an  acute  nature,  the  functional  disturbance  becomes  daily 
more  marked  during  the  period  of  increase ;  the  color  of  the  skin 
is  more  decided ;  the  sensations  and  intellectual  functions  are 
sometimes  deranged,  the  thirst  is  increased,  digestion  becomes 
completely  depraved,  the  tongue  is  more  or  less  coated,  the  pulse 
more  frequent,  the  heat  of  the  body  more  elevated  and  nearly  all 
the  evacuations  are  diminished  or  suspended.  In  chronic  diseases, 
this  period  is  distinguished  by  the  gradual  development  of  the 
principal  symptoms.  Its  duration  may  be  very  short  in  some 
acute  diseases ;  it  is  usually  of  some  months'  continuance  in  chronic 
affections. 

B.  The  second  or  static  period  (violence,  status,  a*^),  is  distin- 
guished by  the  permanent  intensity  of  the  symptoms,  and,  occa- 
sionally, by  the  appearance  of  new  phenomena  of  greater  or  less 
gravity.     It  commences  when  the  aggravation  of  the  symptoms 
ceases,  and  terminates  when  their  intensity  diminishes,  or  when 
the  disease  approaches  a  fatal  termination.     Its  duration  in  acute 
affections  is  usually  shorter  than  that  of  the  first  period,  in  certain 
cases,  however,  it  is  longer. 

C.  The  third  period,  that  of  decline  (decrementum),  or  termina- 
tion, we  now  merely  mention,  intending  to  devote  an  entire  chapter 
to  its  consideration. 

These  three  periods  do  not  exist  in  every  acute  or  chronic  dis- 
ease ;  in  certain  fevers,  the  symptoms  present,  from  the  commence- 
ment, their  highest  degree  of  intensity ;  the  period  of  increase  is 
not  observed.  In  apoplexia  fulminans  there  is  but  one  period;  in- 
deed, it  is  often  instantaneous.  The  same  is  true  of  some  chronic 
affections ;  paralysis  of  any  sense,  deafness  or  amaurosis,  for 
instance,  is  sometimes,  from  the  moment  of  its  occurrence,  as  com- 
plete as  it  will  ever  be  in  the  lifetime  of  the  patient;  neither 
increase  nor  decline  is  observed.  In  some  inevitably  fatal  chronic 
diseases,  the  symptoms  gradually  increase  in  severity  from  the 
commencement  to  the  termination ;  there  is,  as  it  were,  continual 
aggravation :  the  division  into  periods  is  not  applicable  to  these 
cases ;  in  cancer  of  the  stomach,  for  example,  there  are  many  de- 
grees, biit  properly  speaking,  no  periods. 

There  are  some  affections,  on  the  contrary,  in  which  the  three 
periods  are  very  manifest ;  typhoid  fever  is  an  example,  the  exter- 
nal appearance  being  usually  sufficient  for  the  diagnosis  of  the 
disease  and  the  appreciation  of  its  period. 

In  diseases  whose  course  is  intermittent,  each  access  presents  a 
succession  of  phenomena,  somewhat  analogous  to  the  three  periods 
of  an  acute  affection.  Each  of  the  component  parts  of  the  access, 


236  PROGRESS    OF    DISEASES. 

viz.,  the  chill,  the  flush  and  the  sweating,  is  known  by  the  name 
stage  (stadium).  The  chill  has  been  considered  as  the  period  of 
increase,  the  hot  stage  has  been  compared  to  the  static  period,  and 
the  sweating  stage  to  the  termination.  Independently  of  the  three 
stages  presented  by  each  paroxysm,  the  three  periods  of  continued 
disease  may  occasionally  be  distinguished  in  the  aggregate  of  the 
paroxysms.  Thus,  in  the  first  week,  the  paroxysms  progressively 
acquire  a  higher  degree  of  intensity ;  then,  for  about  the  same 
space  of  time,  they  maintain  a  uniform  intensity  ;  a  regular  dimi- 
nution, and  finally,  a  spontaneous  termination  ensue.  But  in  most 
cases,  after  a  few  recurrences  of  the  paroxysm,  we  arrest  the  pro- 
gress of  the  disease,  and  consequently,  can  no  longer  observe  these 
modifications. 

These  periods  are  not  observed  exclusively  in  affections  pro- 
duced by  internal  causes,  they  are  also  evident  in  those  resulting 
from  external  causes.  In  superficial  wounds  we  first  observe  the 
divided  parts  becoming  red,  gradually  swelling  more  and  more, 
and  discharging  a  sero-sanguinolent  fluid  :  when  the  inflammation 
has  become  more  intense,  suppuration  is  established,  and  after  some 
days  the  phlogosis  diminishes,  while  at  the  same  time  the  edges  of 
the  wound  adhere,  and  the  cicatrix  is  formed.  In  this  series  of 
phenomena  we  clearly  distinguish  an  incremental,  a  static,  and  a 
declining,  period ;  something  analogous  takes  place  in  fracture, 
except  that  no  purulent  discharge  exists,  and  that  phosphate  of 
lime  is  deposited  in  the  tissue,  originally  cellular,  afterwards  car- 
tilaginous, which  unites  the  fragments. 

In  terminating  this  paragraph,  it  should  be  remarked,  that, 
however  distinct  the  periods  may  be,  the  transition  from  one  to  the 
other  is  almost  always  gradual  and  imperceptible,  and  that  it  is 
impossible  to  distinguish  between  the  termination  of  one  and  the 
commencement  of  another. 

$  IV.  The  circumstances  capable  of  modifying  the  progress  of 
diseases  are  very  numerous.  Youth  and  adult  age,  sanguineous 
or  bilious  temperament,  and  a  strong  constitution,  hasten  that  pro- 
gress and  awaken  a  more  lively  reaction.  The  diurnal  revolutions 
seem  likewise  to  exert  a  very  decided  influence  upon  the  course  of 
diseases.  Some  of  the  ancient  physicians  thought  that  the  four 
parts  of  the  day  might  be  compared  to  the  four  seasons  of  the  year, 
viz  :  the  morning  to  spring,  mid-day  to  summer,  the  evening  to 
autumn,  the  night  to  winter,  and  that  each  had  an  influence  upon 
the  exercise  of  the  functions  in  health  and  disease,  analogous  to 
that  of  the  seasons.  Testa,  who  published  a  valuable  work  on 
the  periods,  inclined  to  this  opinion,  which  should  be  admitted 
only  with  certain  restrictions.  Before  sunrise,  sweating  is  fre- 
quently observed,  in  both  acute  and  chronic  affections ;  at  this  pe- 
riod, absorption  appears  to  be  somewhat  increased  ;  redema,  when 
inconsiderable,  disappears,  and  diminishes  when  excessive.  It  is 
at  this  time,  as  we  have  previously  said,  that  we  should  employ 
absorbent  remedies.  Cruickshank  assures  us  that  venereal  affec- 


PROGRESS    OF    DISEASES.  237 

tions  which  resisted  frictions  em-ployed  in  the  evening  or  night, 
were  cured  by  them  when  made  in  the  morning.  At  sunrise,  the 
signs  of  plethora  are  more  decided  than  at  any  other  time  ;  the 
body  is  then  more  unwieldy  and  the  .head  heavier  :  in  some 
persons  the  fingers  are  so  swollen  that  they  can  with  difficulty  be 
flexed ;  the  degree  of  heat  is  often  uncomfortable ;  at  this  time, 
also,  the  symptoms  of  cutaneous  inflammation  are  usually  more 
intense.  The  middle  of  the  day  induces  a  slight  paroxysm  in  cer- 
tain chronic  affections,  particularly  in  pulmonary  phthisis,  and 
some  periodical  pains  return  constantly  at  this  hour.  The  evening 
is  the  most  common  season  for  exacerbations  or  paroxysms  in  most 
acute  or  chronic  diseases ;  they  persist  and  increase  in  intensity 
during  the  night,  which  usually  has  an  unfavorable  influence 
upon  affections  of  a  grave  nature.  Patients  at  this  period,  being 
fatigued  by  the  impressions  received  during  the  day,  experience 
more  uneasiness;  their  pains,  if  any  exist,  become  more  severe; 
their  attention  is  not  easily  arrested,  and  their  memory  is  less  sure 
than  in  the  morning.  It  is  almost  always  during  the  night  that 
disorder  of  the  intellectual  functions  begins  to  manifest  itself;  in 
some  patients  it  reappears  every  evening,  and  ceases  wholly  during 
the  day ;  in  others,  delirium,  which  is  calm  through  the  day,  be- 
comes furious  in  the  night.  During  the  night  the  countenance  is 
usually  more  animated,  the  thirst  increased,  the  tongue  less  moist 
or  more  parched,  the  respiration  more  accelerated,  the  pulse  more 
frequent,  the  heat  of  the  skin  more  elevated,  and  the  urine  of  a 
deeper  color. 

Although  the  night  may  have  an  unfavorable  influence  upon  the 
majority  of  diseases,  there  are  many  in  which  this  is  far  more  de- 
cided than  in  others ;  among  these  are  affections  of  the  heart  and 
lungs  (particularly  emphysema,  and  pulmonary  tubercle),  rheu- 
matic pains,  etc.  There  are,  indeed,  certain  affections,  whose 
symptoms  wholly  disappear  during  the  day,  and  manifest  them- 
selves only  in  the  night;  such  are  certain  syphilitic  pains  and 
many  eruptive  diseases,  as  epinyctis.  We  have  also  seen  a  tnor- 
billlform  eruption  reappear  every  night  for  nearly  a  month,  in  an 
individual  who  retained  no  trace  of  it  by  day. 

Some  physicians  have  endeavored  to  discover  the  causes  produc- 
tive of  these  regular  variations  in  the  progress  of  diseases,  which 
correspond  to  the  diurnal  revolutions.  M.  Bally*  asserts  that 
light,  or  its  absence,  different  degrees  of  temperature,  and  the 
unequal  quantity  of  moisture  diffused  in  the  atmosphere,  are  the 
principal  circumstances  which  determine  the  changes  observed  by 
day  or  night  in  the  course  of  diseases.  "Those  manifesting 
themselves  by  exaltation  of  the  vital  forces,  become  aggravated  in 
the  daytime,  those  announced  by  prostration  of  the  same  forces,  in 
the  evening  and  night."  This  writer  adds,  in  support  of  his  opin- 
ion, that  of  eight  cases  of  adynamic  fever,  seven  terminated  fatally 
between  sunset  and  sunrise.  If  his  opinion  be  correct  as  regards 

*  De  rinfluence  de  la  Nuit,  etc.     Theses,  1807,  No.  6. 


238  PROGRESS    OF    DISEASES. 

affections  of  an  adynamic  type,  it  is  far  from  being  true  in  those  of 
an  opposite  nature ;  daily  experience  will  not  allow  us  to  admit 
that  the  paroxysms  of  inflammatory  fevers,  and  of  the  phlegma- 
sise,  take  place  in  the  daytime ;  they  are  almost  without  excep- 
tion observed  in  the  night.  Before  concluding  our  remarks,  in 
regard  to  the  influence  of  the  latter  period  upon  the  progress  of 
diseases,  we  should  draw  attention  to  the  fact  that  it  is  not  always 
injurious,  and  that  frequently  during  its  course,  the  gentle  and 
general  sweats  commence  which  announce  the  arrest  (detente)  of 
the  disease,  according  to  the  common  expression,  and  lead  us  to 
hope  that  a  favorable  termination  is  at  hand. 

The  transient  variations  which  occur  in  the  temperature  and 
moisture  of  the  atmosphere,  and  in  the  direction  of  the  winds,  have 
but  an  uncertain  influence  upon  the  progress  of  chronic  diseases, 
and  seem  to  exert  none  whatever  upon  that  of  acute  affections. 
A  rapid  change  of  temperature,  however,  especially  sudden  and 
severe  cold,  hastens  the  termination  of  chronic  diseases  which  have 
attained  their  last  stage.  This  is  often  observed  in  hospitals ; 
when  the  temperature  from  having  been  for  a  long  time  mild,  sud- 
denly becomes  very  cold,  the  greater  number  of  patients  who,  for 
many  days,  have  been  struggling  with  death,  will  succumb  in  from 
twenty-four  to  thirty  hours.  In  hospitals  allotted  to  old  men,  the 
disastrous  effect  of  cold  upon  the  moribund  is  still  more  evident ; 
but  the  time  of  the  falling  leaf,  so  dreaded  by  the  lower  classes,  is 
not  generally  more  fatal  to  phthisical  patients  than  the  other 
seasons  of  the  year,  when  sudden  changes  of  temperature  occur. 

Many  patients,  more  particularly  those  laboring  under  rheumatic 
and  nervous  affections,  are  persuaded  that  the  intensity  of  their 
pains  augments  or  diminishes  under  the  influence  of  certain  atmos- 
pheric conditions  :  many  such  persons  believe  they  can  accurately 
foretell  the  changes  about  to  take  place  in  the  atmosphere,  by  the 
degree  of  severity  of  their  pains ;  but  observation  does  not  usually 
confirm  their  assertions. 

If  the  transitory  changes  supervening  in  the  atmosphere  have 
but  little  influence  upon  the  course  of  diseases,  it  is  far  otherwise 
in  regard  to  the  important  alterations  arising  from  the  succession 
of  the  seasons  :  their  influence  is  well  established  and  cannot  be 
doubted.  Thus,  during  winter,  catarrhs  and  chronic  discharges 
become  more  severe,  pulmonary  phthisis  advances  with  greater 
rapidity,  chronic  rheumatism  is  more  painful,  dropsical  effusion 
increases  more  rapidly,  and  oedema  of  the  lower  limbs  appears  in 
many  patients  who  had  never  previously  presented  this  symptom. 

The  influence  of  the  heavenly  bodies  upon  the  course  of  diseases, 
is,  in  our  climate  at  any  rate,  quite  as  obscure  as  their  action  con- 
sidered in  the  light  of  a  morbific  cause.  The  rising  of  the  Pleiades, 
the  Dog-star  and  Arcturus.  the  equinoxes  and  solstices,  in  no  de- 
gree alarm  the  modern  physician,  however  respectable  in  other 
ways  may  be  the  authority  which  has  pointed  out  the  disastrous  in- 
fluence of  these  periods  upon  the  course  of  diseases :  this  opinion, 
however,  had  several  advocates  in  the  times  immediately  preceding 


PROGRESS    OF   DISEASES.  239 

our  own.  Baillou.  in  the  first  book  of  his  treatise  on  Epidemics,  re- 
lates the  case  of  a  patient  who  experienced,  during  an  eclipse  of 
the  sun,  an  attack  of  syncope,  which  continued  until  the  reappear- 
ance of  that  luminary.  Ramazzini  states,  that  in  the  night  of  the 
twenty-first  of  January  (this  was  during  the  prevalence  of  epidemic 
petechial  fever),  when  there  was  an  eclipse  of  the  moon,  the  greater 
part  of  the  patients  died,  and  almost  at  the  very  hour  when  the 
eclipse  took  place.  "  Facta  per  noctem  lunari  eclipsi,  major  pars 
cegrotantium  obiit,  ac  eadem  pene  hora  qua  nimirum  luna  labora- 
bat."  *  Balfour,  in  Bengal,  thought  he  could  perceive  that  the 
moon  had  a  physical  action  upon  the  progress  of  various  diseases.! 
Bruce  assures  us  that  he  has  often  noticed,  in  Sennaar,  J  the  in- 
fluence of  this  planet  upon  epileptics ;  and  the  observations  of 
Fontana  support  this  assertion ;  but  all  that  is  known  upon  this 
point  would  not  serve  as  foundation  for  a  sound  opinion.  The 
same  may  be  said  in  regard  to  the  assertion  of  certain  authors, 
Daquin  in  particular,  that  the  moon  has  a  positive  and  constant 
action  upon  the  progress  of  insanity.  M.  Esquirol,  indeed,  has 
also  observed  that  the  insane  were  more  excited  at  the  period  of 
full  moon,  but  he  convinced  himself  that  this  agitation  was  owing 
to  the  penetration  of  lunar  light  into  their  chambers,  for  complete 
exclusion  of  the  light  was  sufficient  to  prevent  the  excitement. 

Among  those  circumstances  which  influence  the  course  of  dis- 
eases, we  should  bear  in  mind  the  greater  or  less  degree  of  salubrity 
of  the  patient's  residence.  Other  things  being  equal,  diseases  are 
less  severe  and  of  shorter  duration  among  isolated  individuals ; 
the  contrary  is  true  in  crowded  hospitals.  This  difference  is  read- 
ily perceived  during  an  epidemic  prevailing  among  all  classes;  the 
influence  of  this  cause  may  be  equally  well  appreciated  by  a  com- 
parison of  the  success  of  operations  done  upon  isolated  and  -upon 
hospital  patients. 

Climate  and  the  aspect  of  the  dwelling,  have  also  a  certain  in- 
fluence upon  the  course  of  diseases:  we  refer  to  our  previous 
remarks  upon  climate  and  situation,  considered  as  morbific  causes. 

The  action  of  heat  and  cold  upon  the  patient's  body,  the  nature 
and  quantity  of  the  food  and  liquids  taken,  exercise  and  rest,  very 
powerful  sensations,  agitation  of  mind,  the  passions,  and  nostalgia, 
are  all  causes  capable  of  modifying  the  course  of  diseases,  but 
productive  of  effects  too  various  for  general  description. 

In  few  diseases  is  the  influence  of  these  different  agents  so  re- 
markable as  in  those  of  the  heart.  In  these  affections,  the  gravest 
symptoms,  such  as  orthopncea  and  infiltration  of  the  limbs,  are 
often  observed  to  disappear  several  times  before  becoming  per- 
manently established :  this  retrograde  course  is  more  particularly 
noticed  among  poor  hospital  patients  ;  in  them,  the  development  of 
these  symptoms  is  often  determined  by  errors  in  diet,  but  particu- 
larly by  fatigue  and  watching,  at  a  period  when  the  organic  lesion 

*  Opera.  SYDENHAM,  t.  ii.  p.  54. 

f  Journ.  de  Mtdecine,  t.  Ixvii. 

^  Voyage  aux  Sources  du  Nil.  t.  viii.  p.  4. 


240  DURATION    OF    DISEASES. 

alone  would  not  have  produced  them.  By  the  simple  removal  of 
these  causes,  by  rest  and  diet,  the  disease  is  reduced  within  its 
appropriate  bounds,  and  the  premature  phenomena  to  which  acci- 
dental circumstances  had  given  rise,  diminish  and  even  disappear 
for  a  certain  time  ;  the  affection  returns  to  the  second  or  even  the 
first  stage,  after  having  apparently  attained  the  third. 

There  is  another  condition  which  has  so  remarkable  an  influence 
upon  the  course  of  chronic  diseases,  that  we  cannot  let  it  pass 
unnoticed;  we  mean  the  state  of  pregnancy.  It  not  only  causes 
the  cessation  of  rheumatic  and  nervous  affections,  etc.,  but  also 
seems  to  suspend  the  progress  of  the  gravest  organic  diseases,  even 
at  an  advanced  stage.  It  is  observed  that  phthisis  often  remains 
stationary  in  pregnant  women ;  many  of  them  survive  the  period 
of  parturition  and  die  shortly  after. 

Before  commencing  another  subject,  we  would  remark  that  the 
various  circumstances  which  modify  the  course  of  diseases  do  not 
prevent  their  exhibiting  a  striking  resemblance,  not  only  in  times 
and  places  nearly  related,  but  also  under  very  dissimilar  condi- 
tions. When  we  read  attentively  the  descriptions  of  disease  by 
observing  physicians  of  every  age,  from  Hippocrates  to  our  own 
times,  we  must  inevitably  recognise  a  great  similarity  between 
diseases  observed  in  widely  separated  ages  and  countries ;  and  not- 
withstanding the  difference  of  climate,  manners  and  other  impor- 
tant circumstances  capable  of  modifying  them.  Baillou  and  Sy- 
denham  in  particular,  have  noticed  epidemic  fevers  similar  to  those 
described  by  Hippocrates  in  the  constitution  of  Thasus,  and  many 
descriptions  by  Aretseus  of  Cappadocia  seem  models  of  the  dis- 
eases observed  in  our  own  times.  —  M. 


CHAPTER  IX. 

DURATION    OF   DISEASES. 

THE  duration  of  diseases  (morbi  mord)  is  the  period  of  time 
between  their  commencement  and  termination. 

It  is  not  always  easy  accurately  to  note  the  duration  of  a  disease, 
from  the  difficulty  of  distinguishing  the  moment  of  invasion,  and 
also  the  exact  period  of  its  termination  ;  if  there  be  the  least  uncer- 
tainty in  respect  to  either  of  these  two  periods,  the  duration  can 
only  be  approximately  determined. 

There  is  still  another  circumstance  which  renders  this  point  in 
pathology  still  more  obscure ;  we  refer  to  the  various  modes  em- 
ployed by  physicians  in  reckoning  the  days.  Some  physicians, 
with  Hippocrates,  reckoned  the  first  day  as  terminating  on  the 
night  following  the  attack,  at  whatever  hour  it  may  have  been, 
and  the  following  days  as  included  between  sunrise  and  sunset. 


DURATION   OF    DISEASES.  241 

Others  make  the  medical  day  to  consist  of  twenty-four  hours,  each 
day  of  the  disease  commencing  and  terminating  at  the  hour  when 
the  latter  first  made  its  appearance. 

Diseases  are  extremely  variable  in  their  duration  ;  when  lasting 
but  one,  or,  at  most,  two  or  three  days,  they  are  called  ephemeral;* 
they  are  termed  acute,  when  their  duration  is  not  over  forty  or 
sixty  days  ;  chronic,  when  prolonged  beyond  that  term.  Ephe- 
meral diseases  have  been  divided  into  ephemeral,  properly  so  called, 
which  last  but  one  day,  and  prolonged  ephemeral,  which  extend 
to  the  second  or  third  day.  Acute  diseases  have  been  also  sub- 
divided into  the  very  acute  (morbi  acutissimi),  which  present  grave 
symptoms,  and  terminate  favorably  or  unfavorably  in  three  or  four 
days  ;  tnorbi  subacutissimi  velperacuti,  which  continue  seven  days  ; 
acute  diseases,  properly  so  called  (morbi  acuti),  whose  duration  is 
fourteen  days;  and  subacute  diseases  (morbi  subacuti),  which  last 
from  twenty-one  to  forty  days.  Chronic  diseases  have  not  under- 
gone similar  subdivision.  These  scholastic  distinctions  are  no 
longer  observed,  and  in  the  more  modern  schools  are  hardly  under- 
stood, having  no  practical  utility;  the  division  into  acute  and 
chronic  diseases  is  the  only  one  generally  admitted. 

The  duration  of  diseases  varies  from  a  few  moments  to  many 
years.  Some  fevers  last  but  one  day;  the  Asiatic  cholera  has 
often  terminated  fatally  in  the  course  of  a  few  hours  ;  there  are 
certain  haemorrhages  which  last  but  a  few  minutes,  and  wounds 
of  the  heart  or  a  large  artery  may  cause  instant  death.  Certain 
rheumatic  affections  terminate  only  with  the  life  of  the  patient. 

There  are  some  diseases  whose  duration  is  fixed  ;  as  rubeola, 
scarlatina  and  variola  discreta,  when  occurring  in  healthy  individ- 
uals ;  the  specific  causes  which  produce  them  generally  determine 
similar  phenomena,  succeeding  each  other  in  a  certain  order,  and 
ceasing  after  a  fixed  time  has  elapsed.  The  duration  of  simple 
wounds  and  fractures,  may  be  approximately  calculated  before- 
hand, according  to  the  seat  of  the  injury,  age  of  the  patient  and 
some  other  circumstances.  The  duration  of  affections  produced 
by  internal  causes  is  more  variable  ;  that  of  pleurisy  may  termi- 
nate in  three  or  four  days  or  be  prolonged  to  thirty,  and  even 
beyond,  when  it  passes  to  the  chronic  state. 

There  are  certain  circumstances  which  exert  a  very  marked  influ- 
ence upon  the  duration  of  diseases.  Many  affections  continue  longer 
after  their  second,  than  after  their  first,  attack.  A  second  ophthalmia 
commonly  lasts  longer  than  when  it  first  appears;  the  same  is  often 
true  of  blennorrhagia.  This  rule  is  by  no  means  without  exception, 
as  it  is  not  rare  to  observe  a  second  peripneumonia,  or  a  second  at- 
tack of  rheumatism,  shorter  than  the  first;  in  the  successive  attacks 
of  erysipelas,  this  disease  diminishes  in  duration  and  severity. 

The  treatment  and  complications  also  exert  a  remarkable  in- 
fluence, as  well  upon  the  duration  as  the  progress  of  diseases  :  these 
two  points  will  be  hereafter  considered.  —  (J. 


tQos;  *7it,  in  j  i^ttga,  day. 

21 


242  TERMINATION.    OF   DISEASES. 


CHAPTER  X. 

TERMINATION    OF    DISEASES.* 


ARTICLE    FIRST. 
Different  Modes  of  Termination.     (Morlorum  eventus.) 

THERE  are  some  affections  which  continue  through  life  and  are 
not  fatal  to  the  patient ;  such  are  certain  forms  of  paralysis  and 
chronic  rheumatism.  Properly  speaking,  these  affections  have  no 
termination ;  but  it  is  otherwise  with  the  majority  of  diseases, 
which  terminate  either  in  the  return  to  health,  in  death,  or  in  some 
other  disease. 

A.  The  return  to  health,  or  the  cure  (morbi  sanatio),  consists  in 
the  complete  restoration  of  all  the  functions.  Its  accompanying 
phenomena  are  exceedingly  various,  as  are  the  diseases  at  whose 
close  they  are  observed.  Our  inability  to  enumerate  them  all  at 
present,  compels  us  to  review  them  generally,  passing  from  the  sim- 
plest to  the  most  complex  cases. 

1.  Among  the  diseases  confined  to  one  portion  of  the  body, 
haemorrhages  and  nervous  pains  are  the  most  simple  in  their  ter- 
mination :  the  flow  of  blood  is  gradually  or  instantaneously  arrest- 
ed, the  pain  ceases,  and  the  disease  is  at  an  end.  The  case  is 
nearly  the  same  in  many  other  affections  characterized  by  one 
predominant  symptom,  as  spasmodic  vomiting  or  nyctalopia  :  the 
gradual  or  rapid  diminution  of  such  a  symptom,  is  the  only  phe- 
nomenon presented  by  the  return  to  health.  In  the  cure  of  the 
phlegmasiae,  the  changes  are  more  varied  and  numerous.  Inflam- 
mation of  the  subcutaneous  cellular  tissue  may  serve  as  an  exam- 
ple ;  in  some  cases,  the  pain,  swelling,  redness  and  heat  disappear 
by  degrees,  in  succession  or  simultaneously,  and  the  inflamed  part 
gradually  regains  its  previous  condition :  this  is  called  resolution. 
In  other  cases,  there  is  purulent  secretion,  constituting  suppura- 
tion ;  the  enveloping  tissues  become  thin,  and  finally  allow  the 
fluid  to  escape ;  in  some  rare  cases,  the  tumor,  at  whatever  stage 
of  development  it  may  be,  not  excepting  that  of  evident  fluctua- 
tion, suddenly  disappears,  leaving  no  trace  of  its  existence,  except 
flaccidity  and  wrinkling  of  the  integuments  :  this  is  termed  reper- 
cussion (delitescence),  and  is  a  favorable  mode  of  termination 
in  inflammations  produced  by  evident  external  causes,  as  bums  of 

*  We  shall  add  some  considerations  upon  critical  phenomena  and  critical  days, 
to  the  account  of  the  different  terminations  and  principal  forms  of  diseases. 


TERMINATION    OF    DISEASES.  243 

the  first  degree,  and  contusions,  but  dangerous  in  those  arising 
from  internal  causes.  The  phlegmasise  occasionally  terminate  in 
gangrene,  as  is  observed  in  furunculus  and  certain  burns  ;  in  the 
former,  a  rounded  eschar,  the  core,  is  discharged  with  the  pus ;  in 
the  latter,  there  is  more  or  less  extensive  sloughing  of  the  integu- 
ments ;  in  both  cases,  the  gangrenous  portion  is  separated  from  the 
living  parts  by  the  pus  effused  between  the  latter  and  the  eschar. 
Cicatrization  gradually  ensues,  as  in  wounds  with  loss  of  sub- 
stance. 

2.  In  general  constitutional  affections,  such  as  continued  fever, 
pestilential  diseases,  eruptive  fevers,  etc.,  the  return  to  health  is 
rarely  sudden :  it  is  in  some  exceptional  cases  only,  that  in  the 
midst  of  the  most  violent  symptoms,  a  calm  suddenly  supervenes, 
which  announces  the  approaching  termination  of  the  disease.     The 
return  to  health  is  most  frequently  progressive,  the  functions  grad- 
ually regain  their  healthy  action,  the  countenance  reassumes  by 
degrees  its  natural  expression,  the  evacuations  are  re-established, 
the  skin  becomes  moist,  the  movements  are  more  easily  executed, 
and  the  patient  feels  himself  improving  daily.     When  the  cure 
occurs  by   means   of  successive  and  distinct  ameliorations,    the 
patient  experiences  in  the  space  of  a  few  hours,  (and  often  after  the 
occurrence  of  phenomena  which  had  not  been  previously  observed, 
as  perspiration  or  alvine  evacuation,)  a  relief  which  apparently 
indicates  incipient  convalescence ;  but  the  symptoms,  after  a  degree 
of  mitigation,  persist  with  the  same  intensity  for  several  days, 
until  a  new  amelioration  occurs  :  usually,  the  second  amelioration 
marks  the  commencement  of  actual  convalescence ;  diseases  have 
occasionally   been   observed    to   persist   beyond   this   point   with 
slighter  symptoms,  and  to  disappear  only  after  a  third  or  fourth 
effort. 

General  affections  whose  course  is  periodical,  such  as  intermit- 
tent fevers,  and  those  diseases  known  by  the  term  masked  fevers, 
sometimes  terminate  suddenly ;  but  more  frequently  their  parox- 
ysms become  irregular  and  incomplete,  and  the  disease  disappears 
gradually. 

3.  At  the  decline  of  local  diseases  which   determine   general 
functional  derangement,   the  same  phenomena  which  are  mani- 
fested in  local  and  general  diseases  are  simultaneously  observed. 
On  one  hand,  peculiar  changes  occur  in  the  affected  organ  ;  on  the 
other,  in  the  functions,  whose  disturbance  was  sympathetic.     Tn 
pneumonia,  for  instance,  the  pain  in  the  side  ceases,  the  respiration 
becomes  freer,  the  cough  less  frequent;    the  sputa,   which  were 
sanguinolent,   are  simply  mucous,   that  part  of  the  chest  which 
returned  a  dull  sound  on  percussion,  regains  its  natural  resonance, 
and  instead  of  morbid  sounds,  we  hear  the  gradually  returning 
vesicular  murmur ;  at  the  same  time  the  face  loses  its  flush,  the 
thirst  and  frequency  of  pulse  diminish,  the  heat  is  moderated,  the 
skin  is  soft  to  the  touch  and  often  moist ;  the  flow  of  urine  is  in- 
creased, appetite  and  strength  return,  etc.     Such  are  the  concomi- 
tant phenomena  of  recovery  in  the  principal  forms  of  acute  disease. 


244  TERMINATION   OF   DISEASES. 

In  chronic  diseases  this  termination  is  almost  always  progres- 
sive :  the  symptoms,  after  having  increased  for  some  time,  diminish 
gradually,  so  that  the  transition  from  disease  to  a  state  of  health, 
as  well  as  its  converse,  is  usually  insensible :  this  is  observed  in 
discharges  and  catarrhs  of  a  chronic  nature,  in  old  ulcers,  scorbu- 
tus,  etc.  In  certain  cases,  indeed,  we  observe  chronic  diseases  come 
to  a  sudden  termination,  as  in  the  disappearance  of  herpetic  eruptions 
of  long  standing,  the  cessation  of  leucorrhea,  the  prompt  cicatriza- 
tion of  ulcers ;  but  these  rapid  cures  are  very  rare  in  chronic 
disease,  and  render  us  anxious  in  regard  to  possible  sequelae. 

B.  The  termination  in  death  takes  place  also  in  various  ways, 
both  in  acute  and  chronic  diseases. —  In  the  former,  it  may  some- 
times occur  suddenly,  either  from  rapid  sinking  of  the  vital  powers, 
as  in  abundant  haemorrhages,  or  before  exhaustion  has  reached  its 
extreme  point,  as  observed  in  certain  typhoid  fevers  and  in  some 
cases  of  confluent  variola ;  it  may  also  happen  by  a  kind  of  as- 
phyxia, or  with  cerebral  symptoms,  as  convulsions  and  coma.— 
Death  may,  at  other  times,  be  announced  many  days  previously  to 
its  occurrence,  by  a  peculiar  alteration  of  the  countenance  and  an 
extreme  feebleness  in  the  motions  and  in  the  voice ;  the  tongue 
becomes  clammy  or  dry,  deglutition  is  noisy,  difficult  or  impossi- 
ble;  respiration  frequent,  unequal  and  rattling;  the  pulse  small, 
weak,  intermittent  or  insensible ;  the  heat  becomes  gradually 
extinct  from  the  extremities  towards  the  trunk  of  the  body;  the 
body  exhales  a  cadaverous  odor,  and  is  partially  covered  with  a 
viscid  and  cold  sweat ;  the  excretions  are  involuntary,  the  sensa- 
tions extinct;  the  patient  differs  only  from  a  dead  body  by  retain- 
ing the  respiratory  movements,  which  take  place  at  intervals,  until 
they  cease  entirely  with  life.  This  state,  to  which  the  term 
agony  *  has  been  applied,  may  last  for  a  few  hours  only,  or  be  con- 
tinued for  many  days,  for  one,  or  even  several  weeks ;  its  usual 
duration  is  from  twelve  to  twenty-four  hours. — In  other  cases  death 
is  preceded  and  announced  by  many  successive  exacerbations  in 
the  symptoms.  This  exacerbation  of  the  symptoms  in  each  suc- 
cessive paroxysm,  is  particularly  observed  in  malignant  intermit- 
tent fevers. 

In  chronic  diseases,  the  termination  in  death  is  rarely  sudden ; 
sometimes,  however,  this  has  been  observed  in  cardiac  aneurism, 
or  in  that  of  the  larger  arterial  trunks,  also  in  pulmonary  phthisis 
and  scorbutus ;  in  all  these  cases  death  usually  takes  place  by 
syncope  :  in  chronic  pleurisy,  when  pus  is  suddenly  and  profusely 
poured  into  the  bronchial  tubes,  rapid  death  by  asphyxia  may 
ensue.  But  in  most  cases,  death  occurs  in  chronic  diseases  by 
progressive  exhaustion  of  the  vital  energies,  the  patient  being  at 
one  time  reduced  to  the  last  degree  of  marasmus,  at  another,  swol- 
len by  serous  infiltration  into  the  subcutaneous  cellular  tissue  and 
effusion  into  the  serous  cavities.  Many  such  patients  retain  their 

v,  a  combat. 


TERMINATION    OF    DISEASES.  245 

intellectual  faculties  and  their  appetite  to  the  last  ;  some  sink  by 
degrees,  without  pain  or  anxiety  as  to  their  fate  ;  others,  in  the 
midst  of  the  most  excruciating  bodily  sufferings  and  the  most 
frightful  despair.  The  majority  present,  three  or  four  days  before 
death,  a  remarkable  alteration  of  the  countenance,  a  state  of 
collapse  and  a  leaden  hue,  which  announce  to  the  physician  the 
approach  of  death. 

C.  Termination  in  another  disease  has  been  termed  by  the 
Greek  physicians,  metaschematismus,  *  an  expression  almost  bar- 
barous to  our  ears.  Peculiar  denominations  have  also  been  pro- 
posed. according  to  the  actual  transformation  of  the  disease  into 
another,  or  to  the  mere  change  of  seat  or  form.  In  the  first  case, 
the  change  supervening  in  the  kind  or  form  of  the  disease,  is  called 
diadoche  (diadoxis)^  in  the  second,  metastasis^  (metastasis),  the 
term  metaptosis  or  metastosis$  has  been  employed  in  the  former 
sense  by  some,  in  the  latter,  by  others.  Metastasis  is  the  only 
term  retained  in  our  language,  the  others  have  become  obsolete. 
Every  displacement  or  transformation  of  disease  is  now  called 
metastasis  ;  the  epithets  favorable  or  unfavorable  are  added,  ac- 
cording as  the  new  affection  is  more  or  less  severe  than  the  former. 

Metastasis  takes  place  frequently  in  acute,  but  is  more  rare  in 
chronic,  diseases.  Rheumatism  often  terminates  by  forsaking  its 
original  seat  for  an  internal  organ  ;  the  same  is  the  case  with 
haemorrhages  :  this  is  metastasis,  properly  so  called,  that  is,  a 
simple  change  of  seat  or  form,  the  disease  remaining  the  same  ; 
while  if  a  haemorrhage  or  a  cutaneous  eruption  succeed  inflamma- 
tion of  the  stomach  or  lungs,  the  disease  which  replaces  the  first 
is  wholly  different  :  this  is  the  diadexis  of  the  ancients. 

Chronic  affections  are  sometimes  observed  to  cease  on  the  ap- 
pearance of  a  cutaneous  eruption  or  of  continued  or  intermittent 
fever.  M.  Sabatier,  in  a  very  interesting  thesis  upon  erysipelas,  || 
has  shown  by  numerous  cases  collected  at  the  Saint  Louis  Hospital, 
that  this  exanthema  is  occasionally  followed  either  by  definitive 
cure  or  by  a  very  favorable  change  in  the  course  of  certain  obsti- 
nate eruptions  which  resist  nearly  all  curative  means,  as  im- 
petiginous  eczema,  sycosis  labialis,  mentagra,  lichen,  and  even 
lupus  and  elephantiasis. 

The  transition  of  the  same  affection  from  the  chronic  to  the 
acute  state,  and  vice  versa,  has  been  referred  to  this  mode  of  ter- 
mination. But  is  not  this  a  simple  change  in  the  course  of  a  dis- 
ease, rather  than  its  termination  in  another  ?  However  this  may 
be,  the  substitution  of  the  acute  for  the  chronic  character  in  disease, 
sometimes  effects  a  cure.  It  is  not,  indeed,  uncommon  to  see 


zuTiaiioc,  transformation  or  change  of  form,   from  a^rtua,  form,   and 
ftrru,  signifying  a  change. 

t  //ictcfo//,,   succession  ;  diadixouai,  I  succeed. 
t  MtTuaTuntc,  from  utraaaw,  to  transfer. 

§  MsTu/iTuxng,   change  of  event;  from  TTTOW,  to  happen,  and    u«r«,  signifying  a 
change. 
||  No.  209,  1831. 

21* 


246  TERMINATION    OF   DISEASES. 

urethral  discharges  persist  for  months  and  even  years,  resisting 
every  kind  of  treatment,  and  finally  be  wholly  cured  when  the 
blennorrhea  is  rendered  acute  by  the  influence  of  some  excess  or 
by  a  new  inoculation  of  the  virus. 

Diseases  arising  from  internal  or  external  causes,  may  terminate 
either  in  death  or  recovery,  but  the  termination  in  another  disease 
seems  peculiar  to  those  produced  by  internal  causes;  for  the  dis- 
eases which  are  owing  to  external  causes  and  exclusively  surgical, 
seem  incapable  of  this  mode  of  termination. 

Such  are  the  three  modes  of  termination  presented  by  diseases. 
Upon  this  point  all  medical  observers  are  agreed ;  it  is  otherwise 
in  regard  to  understanding  and  explaining  the  transition  from 
disease  to  health.  We  here  enter  upon  the  domain  of  conjecture, 
and,  from  that  moment,  must  expect  to  encounter  the  greatest 
diversity  of  opinion. 


ARTICLE    SECOND. 

Doctrine  of  Crises. 

$  I.  THE  term  crisis  *  has  not  been  employed  in  medical  lan- 
guage in  a  strictly  uniform  sense.  Hippocrates  declares  crisis  to 
be  present  when  there  is  marked  increase  or  diminution  of  the  dis- 
ease, when  it  degenerates  into  another,  or  when  it  entirely  ceases.f 
Some  authors  apply  this  term  only  to  the  favorable  or  unfavorable 
changes  supervening  during  the  static,  or  second  period  of  the  dis- 
ease ;  others  make  use  of  it  to  express  a  rapid  and  favorable 
change  observed  in  connection  with  some  new  evacuation,  or  other 
remarkable  phenomenon  ;  others,  finally,  have  given  this  name  to 
the  phenomena  accompanying  the  change,  and  not  to  that  change 
itself.  The  majority  of  modern  physicians  understand  the  term 
crisis  in  one  of  these  latter  acceptations,  which  is  widely  different 
from  that  given  to  it  by  Hippocrates. 

Several  varieties  of  crisis  have  been  admitted  ;  as  salutary  and 
fatal,  regular  and  irregular,  complete  and  incomplete.  The  salu- 
tary are  those  conducive  of  recovery ;  when  prompt  and  preceded 
by  exacerbation  of  the  symptoms,  they  are  crises  properly  so 
named;  they  have  been  designated  by  the  term  lysis'^  (solutio), 
when  mild  and  unannounced  by  previous  exacerbation.  Regular 
crises  are  those  ushered  in  by  precursory  signs,  which  occur  on 
certain  foreseen  days,  and  are  accompanied  by  critical  phenomena ; 
irregular  crises  do  not  present  these  conditions.  Complete  crises 

*  Est  vox  hcec,  crisis,  judicium,  ano  TOV  xQtvioGat,  desumpta  a  for o  judicially 
<juia  inter  spem  vita  metumque  mortis  ancipites  tune  agntrepidant,  veluti  rei  coram 
judice;  incerti  plane,  utrum  crimine  absolcendi  sint,  an  morte  damnandi.     (Pre- 
lect. Ant.  DEHAEN  in  Boerhaave.     Inst.  Path.  t.  ii.  p  5287.) 
Lib.  de  Affection.     LINDEN,  ii.  p.  165. 
^t'<7i$,  solution  ;  from  *t'u>,  I  dissolve. 


TERMINATION    OF    DISEASES.  247 

are  those  which  decide  the  termination  of  the  disease,  by  recovery 
or  death  ;  the  incomplete  leave  the  patient  in  a  doubtful  state. 

The  real  object  of  discussion  has  been  the  existence  of  critical 
phenomena,  not  that  of  crises.  Every  one  admits  changes  of 
favorable  or  unfavorable  nature  in  disease,  and  the  transformation 
of  one  malady  into  another ;  this  we  have  seen  to  be  the  definition 
of  the  term  crisis  as  used  by  Hippocrates,  but  it  is  otherwise 
with  the  accompanying  phenomena  of  crisis;  great  difference  of 
opinion  exists  in  regard  to  their  frequency  and  influence  upon  the 
termination  of  diseases.  Before  examining  these  two  questions, 
we  must  enumerate  the  phenomena  themselves,  and  point  out  their 
antecedent  and  accompanying  signs  and  the  circumstances  favora- 
ble to  their  production. 

A.  Critical  phenomena  may  be  manifested  in  various  parts. 
They  are  most  frequently  observed  upon  the  mucous  surfaces ; 
next  in  frequency  is  the  skin,  thirdly  the  glands,  afterwards  the 
cellular  tissue  and  serous  membranes;  some  of  them  may  also  oc- 
cur in  the  nervous  system.* 

1.  The  mucous  surfaces  present  certain  critical  exhalations  and 
eruptions. 

The  critical  exhalations  from  the  mucous  surfaces  are  of  several 
varieties ;  the  natural  exhalation  may  be  increased,  or  may  become 
an  accidental  sanguineous  or  aqueous  exhalation.  The  mucous 
secretion  of  the  nasal  fossae,  pharynx  and  bronchial  tubes  is  some- 
times augmented  toward  the  close  of  diseases  ;  mucous  stools,  and, 
occasionally,  emesis  of  glairy  matters  have  been  observed  at  such 
periods ;  not  unfrequently  there  is  a  similar  deposit  in  the  urine. — 
Sanguineous  exhalations  from  the  mucous  surfaces,  as  epistaxis, 
hasmorrhoidal  flux  and  metrorrhagia  have  often  been  observed 
under  the  above  conditions,  and  considered  as  critical  phenomena. 
But  few  instances  of  aqueous  exhalation  from  the  mucous  surfaces 
have  been  recorded;  aqueous  emesis  and  catharsis  have  been 
mentioned,  as  being  apparently  critical  of  dropsy. 

One  species  only  of  critical  eruption  has  been  observed  upon  the 
mucous  surfaces ;  this  is  the  apthous  eruption  which  occasionally 
supervenes  in  the  last  stage  of  acute  diseases,  especially  in  children. 

2.  The    skin  likewise   presents   exhalations   and  eruptions  re- 
garded as  critical.     In  the  latter  stage  of  many  acute  diseases, 
pneumonia  particularly,  a  general  perspiration  supervenes,  which 
is  the  more  remarkable  from  the  fact,  that  during  the  first  two  pe- 
riods the  skin  often  remains  dry ;    at  other  times  there  is  only 
slight  moisture  apparent. — The  eruptions  observed  upon  the  skin 
toward  the  termination  of  acute  or  chronic  diseases,  are  very  nu- 
merous.    Erysipelas,  furunculus,  different  species  of  erythema  or 
herpes  are  the  principal ;  the  latter  is  most  frequently  seen  upon. 

*  Dr.  Copland  differs  from  our  author  in  his  enumeration  of  critical  phenomena, 
in  regard  to  their  frequency  of  seat.  He  states  them  to  occur,  1st,  on  the  skin  ; 
2dly,  in  the  cellular  tissue  ;  3clly,  in  the  glands  ;  4thly,  on  the  mucous  surfaces. 
(Med.  Diet.  Art.  Crisis  )  — TRANS. 


248  TERMINATION    OF    DISEASES. 

the  lips;  pemphigus  occasionally  appears  at  the  same  period; 
Storc/c*  and  Morgagni\  have  related  some  very  remarkable  ex- 
amples. The  abundant  purulent  exhalation  produced  by  vesica- 
tion,  and  critical  icterus,  have  been  placed  in  the  same  category, 
although  the  latter  is  more  appropriately  classed  elsewhere. 

3.  The  critical  phenomena  exhibited  by  the  glandular  organs 
may  consist  in  an  increase  of  secretion,  or  in  tumefaction  of  the 
glands  themselves.     Salivation  was  noticed  by  Sydenham  as  a 
critical  evacuation  in  certain  affections;  bilious  stools  and  abun- 
dant flow  of  sedimentary  urine  are  quite  frequent  phenomena  at 
the  decline  of  diseases.     The  lacteal  secretion,   as  we  have  pre- 
viously seen,  is  critical  of  milk  fever. — Tumefaction  of  the  parotids 
sometimes  supervenes  on  the  decline  of  malignant  fevers.     Swelling 
of  the  conglobate  glands  of  the  groin  or  axilla  has  been  considered 
as  critical  by  many  physicians  who  have  observed  and  described 
the  plague ;  but,  in  many  of  these  cases,  has  not  a  tardily  develop- 
ed symptom  been  mistaken  for  a  critical  phenomenon  ? 

4.  The  same  may  be  remarked  of  the  oedematous  swelling  of 
the  cellular  tissue,  mentioned  by  Sydenham  as  a  critical  phenome- 
non   in    intermittent    fever.  J     Subcutaneous    abscess    has    also 
seemed  critical  of  certain  diseases. — Simple  inflammatory  swelling 
of  the  cellular  tissue  has  been  regarded  as  critical  in  certain  cases, 
although  suppuration  might  not  have  taken  place ;  at  the  decline 
of  fevers  a  peculiar  tumefaction  of  the  extremities,  the  face  and 
even  of  the  whole  body,  without  evident  signs  of  inflammation, 
has  been  observed. — Gangrene  of  the  cellular  tissue  and  integu- 
ments has  been  ranked  by  some  authors  among  the  critical  phe- 
nomena of  adynamic  fevers. 

5.  The  critical  phenomena  manifested  by  the  serous  membranes 
are  almost  always  unfavorable.     Occasionally   there   is   dropsy, 
sometimes   sanguineous  effusion   supervening  on   the   decline  of 
another  disease.     The  same  is  the  case  with  synovial  effusion  into 
articular  cavities. 

6.  Finally,  the  nervous  system  has  sometimes  furnished  critical 
phenomena ;  a  sharp  pain  in  the  course  of  a  nerve,  paralysis,  or 
convulsion  of  a  portion  of  the  body,  loss  of  a  sense,  as  hearing, 
sight  or  smell,  and  even  disturbance  of  the  intellectual  functions 
have  been  observed  towards  the  termination  of  diseases,^  and  re- 
garded as  critical. 

B.  Of  the  signs  which  precede  and  accompany  critical  phenom- 

*  Annus  Medicus,ii,  p.  112.  "  Unicus  fuit  teger  in  quo  hac  materies  intra 
scapulas  colligebatur,  et  fiebat  ibi  tumor  qui  magnitudine  caput  virile  excessit ; 
aperto  tumore,  novem  libra  seriflavi  viscidi  effluxerunt." 

f  De  Sedibus  et  Causis.     Lib.  iv.  art.  7. 

|  Opera  omnia,  t.  i.  p.  60. 

§  In  certain  circumstances,  violent  emotion  has  arrested  the  progress  of  an  ob- 
stinate disease,  as  an  intermittent  fever  or  a  convulsive  affection.  Sleep  has  also 
seemed  to  banish  very  severe  pains  which  had  continued  for  many  hours.  But  ad- 
mitting sleep  to  be  a  critical  phenomenon,  it  is  very  certain  that  strong  emotions, 
disconnected  with  the  disease,  cannot  be  so  considered. 


TERMINATION   OF    DISEASES.  249 

en  a,  there  are  some  which  are  common  to  all :  there  are  others 
peculiar  to  each. 

The  common  precursory  signs  are  pain,  more  or  less  severe, 
often,  simple  pruritus,  heat  or  a  sense  of  weight  in  the  organ  about 
to  become  the  seat  of  the  critical  phenomena  ;  to  these  may  be 
added  a  notable  increase  of  the  general  symptoms  of  the  disease, 
especially  the  force  and  frequency  of  the  pulse.  The  usual  con- 
comitant signs  of  critical  phenomena  are  a  sensation  of  amend- 
ment, more  or  less  decided,  and  a  perceptible  diminution  in  most 
of  the  symptoms. 

Critical  phenomena  are  not  always  announced  by  peculiar  signs  ; 
those  which  present  them  most  frequently,  are  the  alvine  evacua- 
tions, haemorrhages,  the  urine  and  the  sweat. 

The  signs  preceding  alvine  discharges  are  borborygtni,  colic, 
distension  of  the  abdomen,  eructation  and  flatulence,  a  sense  of 
tension  in  the  lumbar  region,  pains  in  the  thighs  and  knees,  and  a 
somewhat  irregular  pulse.  The  evacuation  takes  place  without 
pain ;  it  is  copious,  homogeneous,  of  a  yellow  or  brownish  color, 
pultaceons  and,  sometimes,  mucous. 

Critical  epistaxis  is  usually  announced  by  redness,  with  slight 
tumefaction  of  the  face  and  eyes;  occasionally  the  redness  and 
swelling  are  limited  to  one  of  the  alee  nasi,  the  one  corresponding 
to  the  nostril  whence  the  blood  will  flow.  A  dull  pain  in  the  fore- 
head, at  the  root  of  the  nose  or  at  the  nape  of  the  neck,  throbbing 
of  the  temporal  arteries,  tinnitus  aurium,  deafness,  luminous 
spectra,  involuntary  tears,  and,  in  certain  patients,  slight  delirium  or 
somnolency,  precede  epistaxis.  A  quick,  hard  pulse  and  frequent 
respiration  have  sometimes  announced  this  phenomenon  ;  epistaxis 
should  be  copious  to  be  termed  critical. 

Haemoptysis  is  preceded  by  a  sensation  of  heat  in  the  chest,  and 
by  embarrassed  respiration. 

The  signs  indicative  of  haematemesis  are  praecordial  anxiety, 
eructations,  and  all  the  precursory  phenomena  of  vomiting.  Hae- 
matemesis  and  haemoptysis,  as  also  haernaturia,  are  almost  always 
unfavorable  critical  phenomena. 

The  haemorrhoidal  flux  is  announced  by  pain  and  sense  of 
weight  about  the  sacrum,  tenesmus,  and  sometimes  dysuria.  The 
same  precursory  signs  belong  to  metrorrhagia,  with  occasional 
augmentation  or  diminution  in  volume  of  the  mammae,  hypogas- 
tric  colic,  and,  for  each  female  individually,  the  addition  of  the 
phenomena  usually  preceding  her  menstrual  periods ;  these  vary 
in  different  persons. 

Critical  diuresis  is  preceded  by  a  sense  of  weight  in  the  hypo- 
chondria, dull  tension  in  the  hypogastrium,  titillation  in  the  urinary 
organs,  and  diminution  of  cutaneous  exhalation  ;  frequent  excretion 
of  urine  afterwards  takes  place ;  it  is  copious,  usually  high  colored 
when  cool,  and  deposits  a  cohesive,  homogeneous,  white  or  rose 
colored  sediment.  The  addition  of  nitric  acid  sometimes  throws 
down  a  white,  abundant,  albuminous  precipitate. 

Sweating  is  frequently  preceded  by  slight    chills,  diminished 


250  TERMINATION   OF    DISEASES. 

urinary  and  faecal  excretion,  and  occasionally  By  flushing  of  the 
face;  the  elevation  of  the  hypochondria  and  slight  pruritus  of  the 
cutaneous  surface  have  been  mentioned  as  signs  of  this  phenome- 
non. We  have  not  enumerated,  among  these  various  signs,  the 
alterations  in  the  pulse  peculiar  to  each  kind  of  crisis,  because 
experience  has  not  confirmed  the  ingenious  assertions  of  Solano 
and  his  followers.  Physicians  have  also  been  as  prompt  in  aban- 
doning, as  they  were  ready  to  admit,  the  doctrine  of  critical  pulse.* 

*  Bordeu,  the  most  celebrated  historian  of  critical  pulse,  divided  the  pulse  into 
irritative  or  non-critical,  which  is  contracted,  sharp,  hard,  dry  and  quick  ;  and  into 
critical  pulse,  which  is  bounding,  full,  strong,  frequent  and  often  unequal.  The 
latter  is  met  with  in  the  third  period  of  diseases,  the  former  in  the  first.  The 
critical  pulse  is  divided  into  superior  and  inferior :  the  former  indicates  that  the 
crisis  will  take  place  by  some  organ  situated  above  the  diaphragm  ;  the  latter,  that 
it  will  occur  in  one  below  it. 

"  The  superior  pulse  is  remarkable  for  a  rapid  reduplication  of  the  arterial  pul- 
sations :  this  reduplication,  which  is  its  essential  constituent,  seems  originally  to 
be  but  a  single  pulsation  ;  it  is  liable  to  intervals  from  time  to  time ;  these  are 
longer  or  shorter,  more  or  less  frequent,  according  to  the  nature  or  degree  of  the 
disease.  Dilatation,  usually  effected  in  one,  occupies  two  beats,  and  there  are  two 
sensible  efforts  succeeding  a  natural  contraction  of  the  artery. 

'•  The  inferior  pulse  is  irregular,  that  is,  its  pulsations  and  intervals  are  unequal : 
the  intervals  are  sometimes  so  considerable  as  to  constitute  actual  inter mittence, 
according  to  the  kind  of  inferior  pulse  and  in  proportion  as  it  may  be  more  or  less 
marked.  A  sort  of  leaping  of  the  artery  is  sometimes  noticed,  which  serves  in 
some  degree  to  characterize  this  species  of  pulse. 

"The  superior  and  inferior  pulse  may  be  simple,  compound  or  complicated  : 
they  are  simple  when  they  indicate  the  approach  of  crisis  by  a  single  organ ;  com- 
pound, when  the  critical  effort  is  about  to  be  manifested  in  several  at  once  ;  compli- 
cated, when  they  are  united  at  intervals  with  the  irritative  pulse,  during  which 
time  the  critical  effort  seems  interrupted." 

The  different  characteristics  of  the  simple  pulse  are  as  follows  : 

SUPERIOR  PULSE. 

1.  Pectoral.     "  This  is  soft,  full,  dilated  ;  its  pulsations  equal ;  in  each  of  them 
a  sort  of  undulation  is  noticed,  that  is,  the  dilatation  of  the  artery  takes  place  in 
two  beats,  but  with   an  ease,  softness  and  gentle  oscillatory  force,  which  do  not 
allow  us  to  confound  this  kind  of  pulse  with  the  others." 

2.  Guttural.     "  Strong,  with  redoubling  of  each  beat ;  less  soft  and  full,  often 
more  frequent,  than  the  pectoral,  it  is  apparently  intermediate  between  it  and  the 
nasal  pulse." 

3.  Nasal.     "Redoubled  beat  like  the  guttural,  but  fuller  and  harder;  much 
stronger  and  quicker." 

INFERIOR  PULSE. 

1.  Stomachal.     "  Announces  vomiting,  and  is  the   least  developed  of  all  the 
varieties  of  critical  pulse  :  it  is  less  unequal  than  any  of  the  kinds  of  inferior  pulse  ; 
the  artery  seems  to  stiffen  and  tremble  beneath  the  finger  ;  it  is  often  somewhat 
leaping  in  character  ;  the  pulsations  are  frequent,  and  take  place  at  moderately 
equal  intervals." 

2.  Intestinal.     "  More  developed  than  the  former;  the  pulsations  quite  strong, 
as  if  rounded,  and  above  all,  unequal,  as  well  in  their  force  as  in  their  interval, 
which  is  very  easily  distinguished,  since  it  happens  almost  constantly,  that  after 
two  or  three  quite  equal  and  elevated  pulsations,  there  occur  two  or  three  less  de- 
veloped, less  prompt,  nearer  together,  and  as  if  communicating  with  each  other  ; 
from  this  results  a    sort  of  leaping  or  convulsive  effort  ('  explosion  de  Vart ere') 
of  the  artery,  of  greater  or  less  regularity  :  to  the  irregularities  of  this  pulse  very 


TERMINATION    OF    DISEASES.  251 

The  other  critical  phenomena  have  not,  generally  speaking,  pe- 
culiar precursory  signs  ;  in  those  cases  only  where  critical  abscess 
terminates  a  disease,  the  urine  is  sometimes  observed  to  remain 
clear,  and  transient  chills  and  partial  sweats  are  noticed  at  the 
decline  of  the  disease.  * 

At  one  time  a  single  critical  phenomenon  only  is  observed,  as 
copious  haemorrhage  or  profuse  sweating ;  at  another,  many  are 

remarkable  intermittence  is  often  added.  It  is  never  so  full  and  developed  as  the 
superior  pulse  :  its  intermittence  does  not  necessarily  follow  a  definite  order,  on  the 
contrary,  its  disorder  renders  it  easy  of  recognition." 

3.  Uterine.     "  Usually  more   elevated  and   more  developed  than  the  natural 
pulse  :  its  pulsations  unequal ;  the  rebounding  character  is,  it  is  true,  less  constant, 
less  frequent  and  decided  than  in  the  nasal  pulse,  but  is  still  sufficiently  percepti- 
ble." 

4.  Hepatic.     "The  most  concentrated  after  the  stomachal;  neither  hard  nor 
resistant ;  unequal,  its  inequality  consisting   in   the  succession  of  three  or  four 
unequal  pulsations  to  the  same  number  perfectly  equal,   and  which  often  appear 
natural." 

5.  Hamorrhoidal.     "  Unequal,  like  the  other  species  of  inferior  pulse  ;  but  the 
inequality  is  peculiar  to  it.     The  pulsations  have  little  similarity  in  force,  and  still 
less  as  to  interval.     When  less  unequal,  they  seem  almost  always  to  belong  to  the 
state  of  irritation  :  there  are,  however,  occasionally,  some  which  are  fuller,  and  in 
which  the  contracted  character  is  not  so  perceptible  :  when  more  dilated,  they  are 
soon  followed  by  a  rebounding  pulse.     Three  or  four  rather  concentrated  pulsa- 
tions, sharp,  resistant  and  nearly  equal,  are  succeeded  by  two  or  three  somewhat 
dilated,  as  if  rounded  and  less  equal ;  the  three  or  four  following  pulsations  are 
rebounding  in  their  character;  but  these  different  pulsations  have  this  in  common, 
that  there  constantly  exists  a  sort  of  tremor,  greater  frequency  and  depth  of  con- 
traction than  in  the  other  varieties  of  inferior  pulse:  a  depth,  so  to  speak,  is  per- 
ceived in  the  pulsations,  which,  with  the  tremor,  is  the  most  distinguishing  char- 
acteristic between  the  uterine  and  haemorrhoidal  pulse." 

6.  Urinal.     "  Unequal,  with  a  sort  of  regularity  :  there  are   several  pulsations 
gradually  diminishing  in  force  even  to  the  point,  we  might  almost  say,  of  disap- 
pearing beneath  the  finger,    and  recurring  in  the  same  order  from  time  to  time  : 
the  pulsations  in  the  intervals  are  more  developed,  sufficiently  equal  and  slightly 
leaping  in  their  character." 

Sudatory.  "  When  the  pulse  is  full,  pliant,  developed,  and  strong;  when  in 
addition  to  these  modifications,  the  pulsations  become  unequal ;  when  they  in- 
crease to  the  last,  which  is  distinguished  by  a  dilatation  and  at  the  same  time  by  a 
more  decided  suppleness  than  in  the  other  pulsations,  a  critical  sweat  should 
always  be  expected." 

*  Hippocrates  assures  us  that  when  the  urine  continues  transparent  and  crude 
for  a  long  time,  other  signs  being  favorable,  we  should  suspect  abscess  in  some  of 
the  organs  below  the  diaphragm.  (Praenot,  No.  78,  Foes).  The  case  of  Pithi- 
on,  related  by  Hippocrates  in  the  third  book  of  his  Epidemics,  is  not  the  only  one 
confirmatory  of  this  assertion,  however  extraordinary  it  may  appear.  Tissot  has 
given  us  another  in  his  description  of  the  bilious  fever  of  Lausanne,  and  we  have 
ourselves  seen  a  similar  case  in  a  patient  at  La  Charite.  He  was  affected  with 
peripneumonia,  in  the  latter  stage  of  which  the  urine  remained  constantly  trans- 
parent, after  all  the  symptoms  had  completely  disappeared.  He  seemed  convales- 
cent, when  upon  the  seventeenth  day  there  supervened  severe  pain  in  the  left  leg. 
On  the  nineteenth  day,  this  pain  became  throbbing  in  its  character  and  remarkable 
tumefaction  and  hardness  were  added.  Afterwards,  the  pain  and  swelling  in- 
creased and  extended  to  the  thigh  ;  but  on  the  fifth  day,  the  urine,  hitherto  trans- 
parent, became  turbid  and  ammoniacal,  and  the  inflammation,  which  threatened 
suppuration,  terminated  promptly  in  resolution. 


252  TERMINATION    OF    DISEASES. 

met  with  simultaneously ;  in  certain  cases,  all  the  colatoria  seem 
open  at  once;  the  skin  is  covered  with  sweat,  there  is  profuse  flow 
of  urine,  the  bowels  become  relaxed,  the  mucous  secretion  of  the 
nasal  fossae  and  of  the  air  passages  is  increased,  etc.  At  other 
times,  various  critical  phenomena  take  place,  but  successively. 

C.  Critical  phenomena  are  not  in  all  circumstances  equally  evi- 
dent.    They  are  more  distinct  and  frequent  in  youth  and  infancy, 
in  persons  of  strong  constitution,  in  temperate  climates,  in  elevated 
situations,  and  in  the  spring  of  the  year ;  they  are  more  obscure 
in  the  diseases  of  the  aged,  in  feeble  constitutions,  in  moist  situa- 
tions, and  under  the  influence  of  an  active  treatment     Baglivi 
asserted  that  they  were  less  frequent  among  the  inhabitants  of 
cities  than  among  those  of  the  country ;  and  others  have  noticed 
their  greater  frequency  in  the  higher  classes. 

There  are  certain  circumstances  favorable  to  the  production  of 
particular  critical  phenomena.  Critical  haemorrhage  is  more  fre- 
quent in  the  spring  and  in  dry  summers,  in  fertile  countries,  and 
in  those  of  sanguine  temperament  who  are  subject,  when  in  health, 
to  habitual  haemorrhage ;  it  is  chiefly  observed  from  the  age  of 
fifteen  to  thirty-five.  Exhalation  from  the  mucous  surfaces  takes 
place  especially  in  those  of  lymphatic  temperament,  in  wet  seasons, 
as  autumn  and  winter,  and  in  low  and  marshy  grounds.  Critical 
diarrho3a  has  seemed  to  be  more  frequent  in  adults  of  bilious  tem- 
perament, and  in  autumn  ;  critical  diuresis,  in  the  lymphatic,  has 
been  more  often  noticed  in  winter  and  spring. 

If  the  reports  of  some  distinguished  physicians  may  be  credited, 
it  would  seem  that  each  country  imparts  to  disease  a  peculiar  ten- 
dency to  certain  critical  phenomena.  Coray,  in  his  erudite  notes 
to  the  treatise  upon  the  atmosphere,  water,  and  regions,  assures  us 
that  critical  sweats  are  more  frequent  in  Italy  and  in  warm  coun- 
tries generally ;  that  in  Holland  and  England,  urinary  deposits 
are  quite  common ;  that  in  western  France  the  miliary  eruption  is 
more  frequently  critical  of  diseases,  while  at  Paris  critical  phe- 
nomena would  be  more  varied. 

It  has  been  thought  that  there  are  some  critical  phenomena 
which  more  especially  belong  to  diseases  of  certain  cavities.  M. 
Voisin,  in  a  thesis  read  before  the  Parisian  Faculty  of  Medicine, 
asserts  that  thoracic  affections  terminate  most  frequently  by  criti- 
cal phenomena  which  are  manifested  upon  the  cutaneous  surface, 
while  cerebral  affections  usually  terminate  by  alvine  evacuations. 
This  opinion,  founded  upon  a  certain  number  of  observations  and 
upon  the  sympathy  which  exists  between  the  lungs  and  the  skin, 
and  between  the  head  and  the  abdomen,  demands  the  attention  of 
medical  observers. 

D.  The  duration  of  critical  phenomena  is  variable  ;  the  majority 
persist  for  twelve  or  twenty-four  hours  only ;  critical  diaphoresis 
and  diuresis   usually  continue  into  convalescence,  and  their  un- 
seasonable   suppression  often  induces  recurrence  of  the  disease. 


TERMINATION    OF   DISEASES. 

Haemorrhages  sometimes  continue  for  a  few  minutes  only,  while 
certain  eruptions  appearing  at  the  decline  of  diseases,  have  per- 
sisted, in  some  cases,  for  several  months. 

If,  after  the  enumeration  of  these  various  phenomena,  cited  by 
authors  as  critical,  we  would  determine  to  what  extent  they  de- 
serve this  appellation,  we  are  compelled  first  to  examine  their 
frequency,  and  afterwards  their  influence  upon  the  course  of  dis- 
eases. 

There  is  great  difference  of  opinion  among  writers  upon  this  sub- 
ject ;  and,  first,  in  regard  to  the  frequency  of  critical  phenomena  ; 
some  asserting  them  to  be  exceedingly  rare ;  others,  that  they  are 
constantly  present  whenever  treatment  or  a  deteriorated  constitu- 
tion do  not  prevent.  Authorities  and  arguments  have  been  accu- 
mulated on  all  sides,  in  order  to  solve  a  question  which  facts  alone 
can  decide ;  the  numerous  essays  published  upon  this  subject  have 
only  rendered  the  proposed  end  more  remote.  We  do  not  pretend  to 
decide  a  question  so  long  disputed,  but  shall  confine  ourselves  to  the 
simple  exposition  of  the  result  of  our  observations  and  reflections. 

We  remark,  in  the  first  place,  that  this  question  does  riot  seem  to 
us  so  important  as  it  has  been  considered,  and  the  neglect  into 
which  it  has  now  fallen,  confirms,  to  a  certain  extent,  this  opinion. 
However  this  may  be,  the  following  is  our  opinion  in  reference  to 
the  frequency  of  critical  phenomena.  In  very  many  acute  diseases, 
and  especially  in  inflammations  of  moderate  intensity,  we  are  not 
in  the  habit  of  employing  any  of  those  active  means  which  have 
been  regarded  as  peculiarly  suited  to  prevent  the  development  of 
critical  phenomena,  and  we  are  compelled  to  state  that  in  an  im- 
mense majority  of  cases,  we  have  seen  these  diseases  cured  with- 
out any  signification  of  their  resolution  by  remarkable  phenomena  : 
we  cannot  consider  a  slight  moisture,  more  abundant  or  more 
loaded  urine,  or  certain  alvine  evacuations,  as  critical  phenomena ; 
we  regard  them  as  such  only  when  they  draw  the  attention  by 
something  unusual  in  their  nature  or  intensity,  something,  in  short, 
which  distinguishes  them  from  the  common  symptoms  of  these 
diseases.  It  is,  however,  in  exceptional  cases  only,  that  such  phe- 
nomena have  been  observed,  and  in  a  great  majority  of  cases, 
whatever  may  have  been  the  treatment,  the  diseases  have  seemed 
to  us  to  terminate  favorably  or  unfavorably  without  critical  phe- 
nomena of  importance. 

In  regard  to  the  second  question,  which  refers  to  the  influence 
exerted  by  critical  phenomena  upon  the  result  of  diseases,  a  major- 
ity of  the  old  writers  considered  these  phenomena  the  cause  of  the 
re-establishment  of  the  functions  ;  *  that  the  morbific  matter,  prop- 
erly elaborated,  was  excreted  with  the  urine,  the  sweat,  the  faeces, 
etc.,  and  that  the  disease  terminated  in  this  manner  by  the  elimi- 
nation of  its  productive  and  continuing  cause.  This  opinion  has 

*  Critical  phenomena  may  also  correspond  lo  an  exacerbation  of  symptoms,  or 
even  to  the  death  of  the  patients;  but  the  term  is  usually  employed  in  a  favorable 
sense. 

22 


254  TERMINATION    OF    DISEASES. 

been,  latterly,  disputed  by  very  distinguished  physicians,  who 
have  considered  the  phenomena  occurring  at  such  times  as  the 
simple  effect  of  the  re-establishment  of  functions  previously  dis- 
turbed or  suspended.  We  shall  point  out  the  principal  reasons  in 
favor  of  these  two  conjectures. 

Those  who  see  in  critical  phenomena,  and  especially  in  critical 
evacuations,  the  cause  of  re-established  health,  offer  many  argu- 
ments in  support  of  their  opinion.  1.  According  to  them,  the  epoch, 
at  which  these  phenomena  appear,  proves  that  they  are  the  actual 
cause  of  the  return  to  health,  since  they  often  precede  amendment, 
and  are,  in  many  cases,  announced  by  peculiar  signs,  while  the 
disease  is  yet  at  its  height.  2.  The  relief  which  succeeds  these 
critical  phenomena,  and  the  reappearance  of  the  disease  when 
they  are  unseasonably  suppressed,  favor  the  above  opinion.  3. 
These  phenomena  cannot  be  considered  the  effect  of  the  re-estab- 
lishment of  the  functions,  if  we  remember  that  they  differ  very 
much  from  those  presented  during  health  :  the  evacuations  at  the 
termination  of  disease  are  never  similar  to  those  of  health :  the 
urine  contains  sediment ;  the  copious  and  general  sweats  exhale  a 
peculiar  odor ;  the  faeces  are  abundant  and  pultaceous,  etc.  4. 
Can  haemorrhage,  abscess,  pustules  and  apthse,  supervening  on  the 
decline  of  acute  diseases,  be  considered  as  the  effect  of  the  re-estab- 
lishment of  the  functions  alone  ?  Assuredly,  there  is  here  some- 
thing more  than  the  cessation  of  morbid  phenomena.  5.  If  these 
various  proofs,  united,  were  still  insufficient,  it  cannot  be  denied 
that  the  occurrence  of  the  catamenia,  during  the  fever  preceding 
their  first  appearance,  and  the  secretion  of  milk,  in  that  following 
parturition,  are,  incontestibly,  the  causes  which  arrest  the  func- 
tional disturbance.  6.  If,  in  certain  cases,  the  course  of  nature  is 
obscure,  (add  the  partisans  of  this  doctrine,)  such  are  not  the 
circumstances  suitable  for  its  study :  when  the  veil  that  shrouds 
it  is  less  impenetrable,  the  mechanism  of  its  action  may  be  detected. 

Those  who  have  considered  the  phenomena  occurring  at  the 
decline  of  diseases,  as  the  effect,  and  not  the  cause  of  the  return 
to  health,  found  their  opinion  upon  arguments  of  considerable 
plausibility :  1.  The  phenomena  termed  critical  are  generally 
observed  in  one  class  of  diseases  only,  viz.  the  acute  diseases : 
moreover,  it  most  frequently  happens  that  they  are  wanting,  as  is 
proved  by  the  statements  of  even  Hippocrates  and  Forestus^  which 
are  cited  by  the  partisans  of  crisis  :  but  if  these  phenomena  were 
essential  to  the  termination  of  the  disease,  would  they  not  be  of 
constant  occurrence  ?  2.  The  so  called  critical  phenomena  do  not 
always  appear  previous  to  or  at  the  same  time  with  the  amend- 
ment ;  they  often  succeed  it,  and  must  then  be  considered  the  effect, 
and  by  no  means  the  cause,  of  the  change  which  has  supervened. 
The  precursory  signs  which  announce  these  phenomena,  besides 
being  of  very  rare  occurrence,  do  not  prove  them  to  be  actually 
critical :  delirium,  which  is  but  a  symptom  of  disease,  has  its  own 
precursory  signs.  3.  The  same  phenomenon  which  may  be  con- 
sidered unfavorable  or  valueless  in  one  case,  is  regarded  as  favor- 


TERMINATION    OF    DISEASES.  255 

able  in  another,  and  this  at  different  periods  in  the  same  indi- 
vidual :  the  sweats,  for  example,  which  take  place  throughout 
the  disease,  are  considered  unfavorable  during  the  first,  indifferent 
during  the  second,  and  useful  in  the  third  stage ;  is  it  not  more 
natural  to  admit  that  they  are,  in  all  the  periods,  but  one  of  the 
symptoms  of  the  disease,  and  not  a  phenomenon  distinct  from  the 
others  and  capable  of  modifying  its  course  ?  4.  Most  of  the  critical 
evacuations  differ  very  little  from  the  natural :  if  some  exhibit  a 
greater  dissimilarity,  the  difference  should  doubtless  be  attributed 
to  the  former  malady,  and  to  the  still  existing  disturbance  of  the 
functions,  which  only  gradually  recover  their  complete  regularity. 
5.  In  regard  to  diseases  which  appear  at  the  instant  when  others 
terminate,  as  unusual  hsemorrhage,  exanthemata,  etc.,  it  may  hap- 
pen, either  that  the  appearance  of  the  one  class  and  the  cessation 
of  the  other  are  only  a  coincidence,  or  that  the  first  of  these  phe- 
nomena may  be  the  cause  of  the  second.  Supposing  the  latter 
proposition  to  be  true,  it  would  be  proved  that  one  disease  might 
suspend  another ;  but  would  that  prove  that  the  sweats,  the  sedi- 
mentary urine,  etc.,  produce  a  similar  effect?  6.  If  relief  follow 
the  appearance  of  critical  evacuations,  and  if  the  exacerbation  or 
return  of  the  symptoms  be  produced  by  their  suppression,  they 
are  not  thereby  proved  to  be  the  cause  of  this  change.  Suppres- 
sion of  natural  evacuations,  may  excite  in  a  healthy  person  the 
development  of  any  disease  whatever ;  is  it  surprising  that  the 
same  cause  should  produce  analogous  effects  in  one  who  is  debili- 
tated, and  cause  recurrence  of  an  affection  but  just  terminated  1 

By  an  impartial  examination  of  all  the  circumstances  which 
favor  these  two  opposite  opinions,  we  see  how  difficult  it  is,  if  we 
would  not  decide  hastily,  to  adopt  the  one  and  reject  the  other. 
The  partisans  of  critical  phenomena  will  always  cite,  in  support  of 
their  doctrine,  the  lacteal  secretion,  which,  in  the  newly  delivered, 
seems,  indeed,  the  cause  to  which  the  cessation  of  the  antecedent 
fever  must  be  ascribed;  but  if  we  afterwards  consider  the  course 
of  reasoning,  and  the  facts  upon  which  the  contrary  opinion  is 
founded,  its  entire  rejection  will  be  found  difficult. 

The  insufficiency  of  each  of  these  theories  might  perhaps  lead  to 
their  reconciliation,  although  they  are  in  complete  opposition.  If 
we  observe  the  various  resources  of  nature,  and  how  rarely  she 
is  limited  to  an  exactly  uniform  course,  we  might  be  induced  to 
think  that  the  same  phenomena  are  at  one  time  the  effect,  and  at 
another,  the  cause,  of  the  re-establishment  of  the  functions.  It  is 
even  possible  that  the  phenomena  observed  at  the  declining  period 
of  diseases  may  have  relations  with  those  preceding  and  succeed- 
ing them,  which  escape  our  observation.  We  should  not  be  hasty 
in  drawing  general  conclusions,  still  less  so,  in  assigning  bounds 
to  the  powers  of  nature. 

Crises,  in  Hippocratic  language,  being  only  remarkable  changes, 
either  favorable  or  unfavorable,  supervening  in  the  course  of  dis- 
eises,  their  existence  cannot  be  doubted. 

This  is  not  the  case  with  critical  phenomena,  whose  influence 


256  TERMINATION    OF    DISEASES. 

upon  the  termination  of  the  disease,  is,  and  always  will  be,  exceed- 
ingly obscure. 

in  some  few  cases,  these  phenomena  seem  to  play  an  active  part 
in  the  resolution  of  the  disease ;  analogy  would  lead  us  to  suppose 
that  the  same  might  be  true  in  many  other  cases,  where  their  in- 
fluence is  less  evident. 

The  greater  number  of  acute  diseases,  however,  terminate  with- 
out critical  phenomena,  and  the  phenomena  which  have  been  dig- 
nified with  this  name,  are,  for  the  most  part,  nothing  but  new 
diseases,  which  have  supervened  upon  the  decline  of  the  first,  or 
the  tardily  developed  symptoms  of  the  original  disease,  or  lastly, 
the  simple  effect  of  the  re-establishment  of  previously  suspended 
secretions. 


ARTICLE    THIRD. 
Doctrine  of  Critical  Days. 

Do  crises,  that  is,  the  favorable  or  unfavorable  alterations  su- 
pervening in  the  course  of  diseases,  take  place  exclusively,  or  par- 
ticularly, on  certain  days,  or  indifferently  upon  any?  Are  there, 
or  not,  critical  days  ? 

This  doctrinal  point  has  long  been  a  permanent  topic  for  contro- 
versy in  the  schools.  Its  partisans  and  their  opponents  have  been 
drawn,  as  is  almost  always  the  case,  by  the  heat  of  debate,  beyond 
the  point  which  they  wished  to  defend  or  attack.  The  former 
have  thus  been  led  to  assert  that  disease  could  not  be  terminated 
except  on  certain  days,  while  the  latter  maintain  that  no  disease 
whatever  is  restricted  in  its  termination  to  any  particular  day. 

The  following  is  the  doctrine  of  Hippocrates  in  reference  to  criti- 
cal days. 

He  regarded  the  latter  days  of  each  week,  or  period  of  seven 
days,  as  most  favorable  to  the  changes  which  occur  in  disease. 
These  days  are  the  7th,  14th,  20th,  27th,  34th,  and  40th  :  he 
termed  them  critical  days.  Counting  in  this  manner,  the  third 
septenary  period  commenced  upon  the  last  day  of  the  second,  that 
is,  the  14th  day;  the  sixth  week  commenced  upon  the  last  day  of 
the  fifth,  or  the  34th ;  so  that  three  periods,  of  seven  days  each, 
consisted  of  only  twenty  days,  and  six  periods  comprised  but  forty 
days.  Hippocrates,  therefore,  reckoned  twenty-one  medical  days  in 
twenty  solar  days.  Chesneau,  in  his  Treatise  on  Fever,  proposed 
a  medical  day  of  twenty- three  hours ;  but  this  would  not  be  ex- 
actly that  of  Hippocrates,  which  is  somewhat  shorter. 

Hippocrates  placed  those  days  which  occur  in  the  middle  of  the 
septenary  periods,  in  the  second  rank,  as  the  4th,  llth,  and  17th; 
he  named  them  indicatory,  because,  in  his  opinion,  the  alterations 
are  rather  indicated  than  declared,  upon  those  days :  they  are  in- 
dicated either  by  some  new  phenomenon,  or  by  diminished  or  aug- 
mented intensity  of  the  disease. 


TERMINATION    OF    DISEASES.  257 

The  remaining  days  were  divided  into  intercalary,  upon  which 
the  crises  happen  less  frequently,  and  are  less  complete  than  upon 
the  critical  and  indicatory  days,  and  into  vacant  or  non-decretory 
days,  upon  which  crisis  rarely  occurs.  The  days  appertaining  to 
each  of  these  four  series  are  as  follows :  — 

Critical  days,  7th,  14th,  20th,  27th,  34th,  40th,  60th,  etc. 
Indicatory  days,  4th,  llth,  17th,  24th,  etc. 
Intercalary  days,  3d,  5th,  6th,  9th,  etc. 
Non-decretory  days,  2d,  8th,  10th,  12th,  13th,  15th. 

Our  idea  of  the  doctrine  of  Hippocrates  upon  critical  days  would 
be  incorrect  did  we  consider  it  as  exclusive.  This  great  physi- 
cian had  the  wisdom  to  offer  nothing  upon  this  subject  as  being  of 
constant  occurrence ;  he  supposed  that  the  course  of  diseases  was 
modified  according  to  season  and  epidemics.  The  observations 
recorded  in  his  works  are  not  always  conformed  to  his  general 
axioms  upon  critical  days,  and  this  alone  would  prove  that  he  ad- 
mitted exceptions.  He  also  thought  that  crises  might  be  advanced 
or  retarded  a  day,  taking  place,  for  instance,  upon  the  6th,  or  even 
the  8th,  which  is  a  non-decretory  day,  instead  of  on  the  seventh. 

Galen  and  his  followers  were  far  from  imitating  the  circum- 
spection of  the  father  of  medicine ;  they  disfigured  his  theory  by 
asserting  that  certain  days  were  constantly  favorable,  and  others 
always  unfavorable ;  so  that  no  disease  could  terminate  unfavora- 
bly upon  the  7th  day,  nor  favorably  upon  the  6th.  Upon  this 
subject  Galen  calls  to  witness  the  immortal  gods,  who,  says  he, 
know  the  truth  of  my  words  ! 

It  is  as  easy  to  refute  the  exclusive  assertions  of  Galen,  as  it  is 
difficult  to  combat  the  reserved  doctrine  of  Hippocrates.  If  there 
be  a  certain  number  of  affections,  which  may  terminate  indifferently 
at  any  period,  there  are  many  others  whose  cessation,  in  a  fixed 
time,  is  constant,  and  which  have,  as  has  been  remarked,  a  kind 
of  maturity  comparable  to  that  of  the  vegetables;  variola  and 
typhus,  particularly,  are  of  this  class.  Of  forty-eight  cases  of  grave 
fever  recorded  by  Forestus,  thirty  terminated  upon  critical  days, 
eight  upon  indicatory  days,  and  ten  only  upon  the  vacant  or  inter- 
calary days.  By  collecting  all  the  observations  scattered  through 
the  works  of  Hippocrates,  Dehaen  has  shown  that  in  one  hundred 
and  sixty-five  cases  of  acute  disease,  one  hundred  and  sixteen 
complete  or  incomplete  crises  took  place  upon  critical,  or  indica- 
tory da*ys,  and  seventy-seven  only,  upon  other  days.  Favorable 
crises  have  occurred  most  frequently  upon  critical  or  indicatory 
days,  the  unfavorable,  upon  intercalary,  or  vacant  days.^ 

This  influence  of  the  critical  days  is  not  evident  in  internal  dis- 
eases alone ;  it  would  seem  from  the  observations  of  Testa,  that  it 
extends,  in  a  certain  degree,  to  surgical  affections.  According  to 
this  author,  it  is  usually  upon  the"4th,  7th,  llth,  14th,  or  2Uth 
days  that  remarkable  alterations  take  place  in  wounds,  that  ab- 

*  DEHAEN,  Pralect :  in  Boerhaave.     Inst.  Path.  t.  ii.  p.  276. 

22* 


258  TERMINATION    OF    DISEASES. 

scess  discharges  itself,  that  favorable  evacuations,  and  the  acci- 
dents of  disease,  particularly  convulsions,  supervene. 

The  opponents  of  the  doctrine  of  critical  days  have  asserted  that 
it  was  not  observation  which  led  Hippocrates  to  its  establishment, 
but  that  he  was  prejudiced  in  favor  of  the  numerical  system  of  Py- 
thagoras. CelsuSj  in  particular,  thus  indirectly  reproaches  Hippo- 
crates, when  he  accuses  the  old  physicians  of  having"  referred  the 
periods  of  disease,  and  the  critical  days,  to  the  power  of  numbers. 
When  we  reflect  upon  the  circumspection  with  which  Hippocrates 
expresses  himself  in  regard  to  the  influence  of  critical  days,  we 
find  it  difficult  to  reconcile  language  so  reserved  with  such  a  pre- 
judice as  has  been  mentioned.  If  we  compare  the  numerical  doc- 
trine of  Pythagoras  with  that  of  the  critical  days  of  Hippocrates, 
we  shall  be  still  more  convinced  that  the  latter  was  not  blinded  by 
Pytha gorism.  The  attentive  perusal  of  the  writings  of  Hippocrates 
does  not  allow  us  to  suppose  that  he  attached  so  much  importance 
to  numbers  in  general,  and  to  unequal  numbers  in  particular,  as 
has  been  generally  believed.  The  doctrine  of  critical  days,  as  pre- 
sented in  his  authenticated  works,  is  so  different  from  that  con- 
tained in  the  books  incorrectly  attributed  to  him,  that  it  becomes 
concurrent  proof  in  showing  the  slight  foundation  that  exists  for 
the  distinction  which  has  been  made. 

We  shall  not  go  so  far  as  to  assert  that  the  researches  of  Hippo- 
crates upon  critical  days  are  wholly  foreign  to  the  system  of 
Pythagoras ;  but  it  is  another  thing  that  this  system  suggested  to 
Hippocrates  the  idea  of  critical  days,  or  that  this  physician  was 
led  by  that  system  to  observe  them ;  if,  therefore,  it  be  proved  that 
the  numerical  doctrine,  and  that  of  critical  days,  although  to  a  cer- 
tain extent  analogous,  differ  in  many  respects;  if,  as  would  be 
easy  to  show,  they  are,  in  many  points,  in  complete  opposition,  it 
cannot  be  admitted  that  the  doctrine  of  critical  days  is  only  the 
application  of  the  system  of  Pythagoras  to  the  course  of  diseases, 
and  we  are  forced  to  the  conclusion  that  Hippocrates  relied  mainly 
upon  his  own  observations  in  announcing  a  doctrine,  the  idea  of 
which  might  have  been  suggested  to  him  by  the  numerical  system. 

Most  of  the  discussions  which  have  arisen  concerning  critical 
days,  might  have  been  avoided  if  the  point  in  debate  had  been 
better  understood,  and  each  disputant  had  clearly  expressed  to  what 
extent  he  wished  to  question  or  defend  this  opinion.  Almost  all 
these  partisans  willingly  agreed  that  diseases  did  not  undergo  re- 
solution in  every  case,  without  exception,  upon  critical,  or  fhdica- 
tory  days,  and,  very  probably,  the  majority  of  their  opponents 
would  have  admitted  that  there  are  certain  days  upon  which  the 
changes  in  diseases  are  somewhat  more  frequent ;  from  that  mo- 
ment the  question  would  no  longer  have  turned  upon  the  relative 
frequency,  and  the  observations  subsequently  made,  with  the  in- 
tention of  elucidating  this  latter  point,  would  have  had  at  least  the 
advantage  of  enriching  the  annals  of  science,  even  if  they  left  this 
question  undecided ;  for  it  is  peculiar  to  exact  observations,  that, 
even  when  they  fail  to  attain  the  observer's  object,  they  remain 


CONVALESCENCE.  259 

forever,  useful  monuments  for  consultation,  and  suitable  aids  in  the 
solution  of  the  questions  daily  arising  by  reason  of  the  progress  of 
medicine. 

Before  terminating  this  article,  we  would  remark  that  the  doc- 
trine of  critical  phenomena,  and  that  of  critical  days,  are,  to  a 
certain  extent,  independent,  and  that  one  may  be  well  founded, 
and  the  other  not. 

In  conclusion,  we  would  add,  that  the  doctrine  of  critical  days, 
like  that  of  critical  phenomena,  does  not  possess  the  importance 
which  has  been  attributed  to  it ;  that  the  difficulty  of  fixing  the 
days  of  the  invasion  and  termination  of  diseases,  renders  it  inap- 
plicable in  many  cases,  and  that  it  allows  both  the  adherents  and 
antagonists  of  this  theory  to  interpret  the  same  facts  to  their  ad- 
vantage. —  M. 


CHAPTER    XL 

CONVALESCENCE. 

CONVALESCENCE  (convalescentia)  is  an  intermediate  state  between 
disease,  which  no  longer  exists,  and  health,  still  unrestored :  it 
commences  when  the  characteristic  symptoms  of  the  disease  have 
disappeared,  and  terminates  at  the  period  when  that  free  and 
regular  functional  action,  constituting  health,  is  fully  re-established. 

The  term  convalescence  consequently  supposes  a  certain  degree 
of  gravity  in  the  antecedent  disease.  After  simple  indisposition, 
or  the  cure  of  certain  local  affections,  there  is  no  convalescence. 

Convalescence  has  been  divided  into  the  real  and  the  fallacious  : 
this  division  cannot  be  admitted.  If  disease  persist  after  a  marked 
remission,  the  individual  is  yet  ill ;  if  it  have  ceased,  he  is  conva- 
lescent. Convalescence  may  be  uncertain,  but  is  never  fallacious. 

The  phenomena  of  convalescence  necessarily  vary,  like  those  of 
the  antecedent  disease.  They  have,  however,  certain  points  in 
common,  both  in  acute  and  chronic  affections. 

In  the  latter,  the  slowness  with  which  the  re-establishment  of 
the  functions  takes  place,  constitutes  the  principal  character  of 
convfcescence :  the  countenance  long  retains  the  impression  of 
disease ;  the  healthy  standard,  as  regards  flesh  and  strength,  is  not 
regained  for  several  months;  the  appetite  languishes  for  a  long 
time,  the  stomach  and  intestines  are  inactive.  An  entire  year 
often  elapses  before  complete  recovery  is  attained  ;  and  in  certain 
persons,  especially  those  of  advanced  age,  the  system  experiences, 
for  an  indefinite  period,  the  effects  of  the  powerful  shock  it  has 
received. 

The  phenomena  which  accompany  convalescence  from  acute 
disease,  are  far  more  numerous  and  remarkable.  One  of  the  first 


260  CONVALESCENCE. 

effects  of  the  cessation  of  disease  is  a  rapid  emaciation  of  the 
whole  body,  particularly  of  the  face,  which  becomes  paler.  This 
emaciation  and  pallor  seem  especially  connected  with  the  cessation 
of  the  febrile  action,  and  with  the  diminution  of  heat ;  for  even  in 
the  living  body,  heat  determines  an  increase  of  volume  in  its  con- 
stituent parts,  an  actual  rarefaction  of  the  solids  and  fluids ;  the 
re-establishment  of  the  secretions  during  the  third  period,  has  also 
a  certain  influence  in  diminishing  the  volume  of  the  body.  At  the 
same  time  that  the  convalescent  experiences  relief  from  the  cessa- 
tion of  his  pain  or  uneasiness,  his  loss  of  strength  becomes  more 
evident :  it  is  with  tottering  steps  and  great  effort  that  he  first 
attempts  to  walk ;  his  voice  remains  for  some  time  feeble,  and 
regains  by  degrees  only,  its  natural  tone.  This  prostration  extends 
likewise  to  the  intellectual  faculties:  imagination,  memory  and 
judgment,  it  is  true,  are  freely  exercised  by  the  majority  of  indi- 
viduals ;  but  violent  mental  exercise  induces  instant  fatigue,  head- 
ache or  other  morbid  phenomena.  It  is  also  observed  that  the 
convalescent  state  is  accompanied  by  remarkable  increase  of  the 
nervous  susceptibility ;  convalescents,  although  inclined  to  agree- 
able thoughts,  are  impatient  and  irascible,  and  physical  and  moral 
impressions  often  cause  them  a  shock  out  of  proportion  to  the 
determining  cause  and  the  usual  impressibility  of  the  patients. 

The  regular  action  of  the  digestive  functions  is  but  gradually 
resumed ;  the  tongue  continues  slightly  coated,  appetite  does  not 
always  return  promptly ;  wine  often  has  a  bitter  taste,  and  bread 
is  tasteless ;  thirst  diminishes  or  ceases ;  in  the  majority  of  cases, 
appetite  returns  more  quickly  than  the  powers  of  digestion,  and  ; 
this  is  the  cause  of  the  attacks  of  indigestion  so  frequent  among 
the  convalescent :  some  persons,  however,  eat,  and  digest  with 
ease,  a  considerable  amount  of  food,  from  the  first  day  of  conva- 
lescence from  grave  disease.  We  have  observed  two  convalescents 
from  typhus  fever  take,  without  injury  and  at  one  meal,  upon  the 
very  day  of  the  cessation  of  the  disease,  more  than  half  a  pound 
of  solid  food.  Hildenbrand  has  made  analogous  observations :  he 
relates  that  the  appetite  often  amounts  to  actual  voracity.  *  Cos- 
tiveness  is  usually  noticed  during  convalescence  from  acute  disease ; 
sometimes,  on  the  contrary,  there  is  diarrhoea.  Respiration  is  easy 
while  the  person  is  at  rest,  but  exercise  and  conversation  cause 
dyspnoBa.  The  pulse  often  remains  frequent  for  many  days  ;  but 
if  all  the  other  signs  are  favorable,  this  frequency  need  not  alarm 
us ;  it  should  not  deter  the  physician  from  allowing  the  con^les- 
cent  the  food  they  request.  In  certain  persons  the  pulse  becomes 
slower  than  in  the  healthy  state,  owing,  doubtless,  to  the  rest  and 
long  continued  diet  required  by  the  disease  :  there  may  be  but 
fifty,  or  even  fewer  pulsations  in  a  minute.  Most  convalescents 
experience  palpitations,  even  from  the  slightest  causes,  as  walking, 
or  from  the  effect  of  a  lively  sensation  or  emotion ;  these  are,  how- 
ever, by  no  means  alarming;  in  the  anaemic,  a  bellows'  sound  is 

*  Typh.  Contag.  Trad,  de  Gasc.  p.  86. 


CONVALESCENCE.  261 

usually  heard  in  the  heart  and  large  arteries :  in  almost  all  cases 
the  lower  limbs  swell  readily,  when  the  upright  position  is  long 
maintained,  and  in  the  evening  slight  oedema  is  perceived  around 
the  ankles.  Convalescents  are  habitually  cold,  even  in  the  warm 
season,  either  because  their  natural  heat  is  diminished,  or  because 
a  prolonged  continuance  in  their  apartments,  and  in  bed,  has  ren- 
dered them  more  susceptible  to  external  cold.  In  very  many,  the 
cutaneous  transpiration  is  abundant  during  sleep,  and  the  secretion 
of  urine  is  also  increased.  The  grayish  color  of  the  faeces,  often 
noticed,  and  the  infrequency  of  their  discharge,  lead  us  to  suppose 
that  the  biliary  secretion  is  diminished  at  the  commencement  of 
convalescence. 

One  of  the  most  remarkable  phenomena  of  convalescence,  is  the 
excitement  of  the  generative  organs,  causing  strong  venereal  desire, 
lascivious  dreams,  and  nocturnal  pollutions.  Many  authors  relate 
that  old  men  who  had  not  had  any  ejaculation  for  years,  have 
experienced  it  during  convalescence.  The  menstrual  discharge 
frequently  does  not  recur  for  many  months  after  the  cessation  of 
the  disease. 

To  the  above  phenomena,  we  shall  add  the  desquamation  of  the 
cuticle  and  the  loss  of  the  hair,  which  occur  in  many  individuals 
at  a  very  advanced  stage  of  convalescence.  These  phenomena 
are  often  observed  after  grave  diseases,  and  especially  after  those 
accompanied  by  an  eruption  upon  the  skin,  even  if  obscure,  as  in 
typhoid  fever.  The  hair,  when  renewed,  has  not  its  original  color 
or  form,  and  from  this  arises  its  peculiar  appearance  in  convales- 
cents from  severe  disease. 

To  finish  the  picture  of  convalescence,  we  should  mention  the 
feeling  of  comfort,  which  is  more  and  more  lively  in  proportion  to 
the  completeness  of  the  restoration,  and  those  new  delights  tasted 
by  the  convalescent  in  the  simple  performance  of  the  most  ordinary 
acts  of  life  ;  delights  unknown  to  one  who  has  never  been  ill.  "  No 
one,"  said  Hildenbrand,  "  has  experienced  pleasure  in  perfection, 
if  he  has  not  felt  that  which  arises  during  convalescence  ..." 
Indeed,  it  is  only  when  we  have  been  deprived  of  health,  as  of  any 
other  enjoyment,  that  we  can  really  appreciate  it. 

The  duration  of  convalescence  is  often  uncertain,  because  the 
epoch  of  its  commencement  and  termination  are  not  well  defined. 
It  can  hardly  ever  be  accurately  determined;  its  proximate  duration, 
only,  can  be  known. 

Ma%  conditions,  moreover,  may  prolong  or  abridge  convales- 
cence. The  age  and  constitution  of  the  individual,  the  nature  and 
duration  of  the  affection,  the  treatment,  dwelling,  season  and  reg- 
imen, are  those  most  influential  in  determining  the  time  which  will 
elapse  between  the  termination  of  the  disease,  and  the  complete  re- 
covery of  health.  Other  things  being  equal,  convalescence  is  shorter 
in  infancy  and  youth  ;  it  is  longer  in  persons  habitually  feeble  and 
indisposed ;  in  damp  situations,  in  those  where  the  houses  are 
below  the  level  of  the  ground,  and  in  hospitals,  than  in  opposite 
circumstances.  The  ingestion  of  unwholesome  food,  too  rigorous 


262  CONSECUTIVE    PHENOMENA. 

diet,  or  the  opposite  extreme,  prolong  the  period  of  convalescence. 
It  has  likewise  been  observed  to  be  shorter  in  spring  than  in 
autumn  and  winter.  Finally,  it  is  of  very  constant  occurrence, 
that  it  is  generally  shorter  after  inflammatory  diseases,  than  after 
those  accompanied  by  great  prostration.  Excessive  evacuations, 
(especially  the  sanguineous,)  either  spontaneous  or  artificial,  occur- 
ring in  the  course  of  a  disease,  prolong  convalescence. 

When  we  attentively  observe  the  changes  which  supervene  dur- 
ing convalescence,  we  generally  remark  a  daily  increase  in  the 
regularity  of  action  and  freedom  of  the  various  functions ;  but  we 
notice  that  the  recovery  does  not  take  place  with  like  uniformity 
and  promptitude  in  the  different  organs.  Not  only  are  those  which 
were  primarily  and  principally  affected  generally  the  last  to 
recover  their  energy,  but  among  those  secondarily  affected,  a 
certain  number  do  not  regain  their  normal  state  for  some  time 
after  the  others.  Convalescence  is  a  complex  phenomenon  ;  it  is 
composed  of  the  partial  re-establishment  of  each  of  our  organs :  it 
may  be  complete  in  one  patient,  while  it  has  hardly  commenced  in 
another. 

Established  convalescence  does  not  always  lead  to  an  immedi- 
ate and  complete  recovery  of  health :  it  may  be  impeded  in  its 
course  by  certain  phenomena  which  are  not  of  sufficient  severity 
to  constitute  a  morbid  condition ;  it  may  be  interrupted  by  the 
recurrence  of  the  disease  which  preceded  it.  These  two  points  in 
the  history  of  disease  will  be  examined  in  the  two  following  chap- 
ters. —  M. 


CHAPTER    XII. 

CONSECUTIVE    PHENOMENA. 

BY  the  words  consecutive  phenomena,  are  denoted  those  various 
disturbances  of  the  functions  which  continue,  or  make  their  first 
appearance,  after  the  natural  termination  of  diseases.  They  are 
sometimes  confounded  with  the  phenomena  of  a  prolonged  conva- 
lescence, but,  in  general,  are  widely  different,  not  only  in  degree, 
but  because,  for  the  most  part,  they  affect  a  single  functiorr^only, 
while  convalescence  is  distinguished  by  a  general  debility  affecting 
alike  all  the  organs  of  the  economy. 

One  of  the  most  familiar  examples  of  a  consecutive  phenome- 
non, is  the  yellow  color  of  the  integuments  which  sometimes  con- 
tinues after  the  causes,  which  have  produced  any  obstruction  to  the 
secretion  or  excretion  of  bile,  have  ceased  to  act,  as  is  apparent 
from  the  entire  re-establishment  of  the  digestive  functions,  the 
normal  color  of  the  urine  and  fasces,  and  the  perfect  regularity  of 
all  the  functions ;  the  icterus,  in  these  cases,  is  no  longer  a  symp- 


CONSECUTIVE   PHENOMENA.  263 

torn,  since  'there  is  no  disease.  The  impregnation  of  the  integu- 
ments by  the  coloring  matter  of  the  bile,  is  the  persistent  effect  of 
a  morbid  condition  which  has  ceased  to  exist ;  it  is  not  the  sign 
of  a  present  disease,  but  only  the  consequence  of  a  disease  already 
terminated ;  and  this  icterus,  which,  at  the  time  of  its  first  appear- 
ance, was  included  among  the  symptoms,  properly  so  called,  is  now 
but  a  consecutive  phenomenon. 

Of  these  consecutive  phenomena,  some  are  contemporaneous 
with  the  disease,  as  for  example,  pain  in  the  side  in  cases  of  pneu- 
monia ;  others  appear  a  certain  number  of  days  after  the  com- 
mencement, but  a  considerable  time  before  the  termination,  of  the 
disease.  An  instance  of  the  latter,  is  the  yellow  color  of  the  skin, 
which  shows  itself  after  seven  or  eight  paroxysms  of  intermittent 
fevers,  and  which  continues  for  a  greater  or  less  time  after  conva- 
lescence. There  are  others  which  make  their  appearance  when 
the  disease  begins  to  abate,  and  on  this  account  have  been  consid- 
ered by  many  physicians  as  critical  phenomena  ;  and,  finally,  there 
is  still  another  class  of  these  phenomena  which  are  only  known  to 
exist  after  complete  recovery,  as  the  oedema  which  follows  a  great 
number  of  diseases. 

It  is  apparent  from  this  brief  classification,  that  the  consecutive 
phenomena  of  diseases  are  very  numerous  and  of  various  descrip- 
tions ;  we  only  propose,  however,  in  the  following  pages,  to  give  an 
enumeration  of  the  principal  ones  that  come  under  our  observation. 

Many  persons  experience,  after  sickness,  a  remarkable  dimi- 
nution or  increase  in  the  size  of  the  body.  In  the  first  case, 
instead  of  recovering  their  natural  embonpoint,  they  continue  to 
lose  flesh,  in  the  same  manner  as  during  sickness ;  in  the  latter,  of 
which  Tissot  saw  many  examples,  they  discover  an  alarming  ten- 
dency to  obesity.  In  other  cases  of  convalescence,  the  patient  is 
left  with  a  debility  which  affects  the  movements  of  the  whole  body, 
or  particular  parts  of  it,  and  sometimes  with  a  trembling,  more  or 
less  general.  Hoarseness  of  the  voice  continues  after  some  cases 
of  angina  and  certain  nervous  affections.  Pains  are  very  common 
consecutive  phenomena  after  herpes  zoster  and  other  phlegmasiae. 
The  organs  of  sense,  particularly  those  of  sight  and  hearing,  re- 
main oftentimes  enfeebled  after  the  other  functions  are  completely 
re-established.  Delirium  was  observed  by  Hippocrates,  and  Piquer 
saw  two  examples  of  it.  We  have  also  ourself  observed  it.  Entire 
sleeplessness  is  also  a  common  consecutive  phenomenon.  Tissot 
thinks* that  this  may  be  owing,  in  some  cases,  to  the  loss  of  habit. 
Sometimes  we  see  various  disorders  of  the  digestive  functions, 
such  as  loss  of  appetite,  weakness  of  the  stomachic  digestion,  and 
constipation  so  obstinate  as  to  resist  the  most  energetic  treatment. 
Cough,  hiccup,  and  frequency  of  the  pulse,  sometimes  remain  after 
the  other  functions  have  recovered  their  natural  exercise.  Exces- 
sive perspiration  and  abundant  flow  of  the  urine,  are  two  phenom- 
ena that  often  appear  after  acute  diseases,  and  one  or  the  other 
almost  invariably.  Sometimes  they  occur  alternately  until  the 
health  is  completely  re-established.  Their  suppression  is  liable  to 


264  RELAPSE    AND    RECURRENCE. 

be  followed  by  an  increased  exhalation  in  the  cellular  tissue,  and 
the  supervention  of  anasarca. 

To  the  consecutive  phenomena  above  enumerated,  may  be  added, 
abscesses,  gangrene  and  hectic  fever  resembling  phthisis.  These, 
however,  are  rather  diseases,  than  simple  consecutive  phenomena. 

Consecutive  phenomena  may  increase  or  diminish  in  intensity, 
or  remain  stationary.  They  are  various,  also,  in  as  far  as  they 
possess  sometimes  a  continuous  and  sometimes  a  periodic  charac- 
ter. The  pains  which  follow  herpes  zoster,  the  dyspnoea  which 
follows  pneumonia,  are  continuous  like  those  affections.  On  the 
other  hand,  the  phenomena  which  remain  or  make  their  appear- 
ance after  periodical  diseases,  have  the  same  periodical  character. 
Thus  after  intermittent  fevers,  we  observe  phenomena  differing 
with  regard  to  form  and  duration,  and  making  their  appearance  at 
intervals  corresponding  to  the*  attacks  of  the  fever,  as  a  momentary 
chill  of  the  whole,  or  any  part  of  the  body,  transient  heat,  a  pain 
or  spasm,  and  a  brick  colored  sediment  in  the  urine.  Phenomena 
are  sometimes  observed,  however,  after  diseases  of  this  sort,  which 
have  not  this  periodical  character.  Of  this  class,  are  the  swelling 
of  the  spleen,  ascites,  and  the  oedema  of  the  lower  extremities, 
which  continue  for  a  greater  or  less  time  after  intermittent  fever. 

We  can  lay  down  no  general  rule  with  respect  to  the  duration 
of  consecutive  phenomena.  Generally  speaking,  however,  they 
do  not  continue  above  two  or  three  weeks,  though  sometimes 
longer.  The  weakness  or  stiffness  of  limbs,  which  sometimes  fol- 
lows rheumatic  affections,  has  been  known  to  continue  during 
life.  — O. 


CHAPTER  XIII. 

RELAPSE   AND    RECURRENCE. 

BY  the  term  relapse  is  signified  the  renewal  of  a  disease  during 
the  period  of  convalscence ;  by  recurrence  (morbus  recidivus),  is 
understood  the  reappearance  of  a  disease  after  the  complete  restor- 
ation of  health. 

Relapse  is  commonly  produced  by  some  occasional  cause :  ex- 
posure to  cold,  an  error  in  diet,  excessive  exercise,  a  violent  emo- 
tion, immoderate  use  of  medicine,  are  the  most  frequent  causes 
of  the  return  of  a  disease. 

Relapse  is  not  of  equal  frequency  in  all  affections;  there  are 
some  diseases,  as  the  contagious  eruptive  fevers,  in  which  it 
never  takes  place;  there  are  others,  as  peripneumonia  and  pleu- 
risy, in  which  it  rarely  occurs ;  and  finally,  still  others,  as  inter- 
mittent fevers,  in  which  it  is  of  frequent  occurrence.  The  fre- 
quency of  relapse  in  the  latter  affection  has  been  attributed  to  the 


RELAPSE  AND  RECURRENCE.  265 

course  of  these  fevers,  which  have  a  marked  tendency  to  repro- 
duce themselves,  and  to  the  kind  of  habit  the  economy  seems  to 
have  contracted,  when  the  paroxysms  have  been  many  times  re- 
peated. A  remarkable  circumstance  connected  with  the  relapse  of 
intermittent  fevers,  is  their  almost  uniform  occurrence  at  the  day 
and  at  the  hour,  when  the  fever  should  have  appeared,  had  not 
the  paroxysms  been  suspended.  Strack  remarked  that  he  had 
sometimes  seen  this  regularity  in  the  recurrence  of  fevers,  after  the 
lapse  of  several  months  and  even  a  year  ;  but  the  latter  cases  are 
very  rare,  and  may  admit  of  doubt ;  for  however  little  the  parox- 
ysm be  advanced  or  retarded,  how  can  the  application  of  the  cal- 
culation to  so  considerable  a  lapse  of  time  hold  good  ? 

The  symptoms  accompanying  relapses  are  nearly  the  same  with 
those  of  the  primary  affection.  There  is  generally,  however,  more 
debility,  which  may  increase  the  danger.  Their  duration  is  ordi- 
narily longer,  and  when  the  life  of  the  patient  is  spared,  they 
generally  leave  him  in  a  state  of  debility,  from  which  he  recovers 
but  slowly,  and,  in  some  cases,  never  regains  his  strength.  But 
to  this  assertion  there  are  numerous  exceptions ;  thus,  the  reappear- 
ance of  erysipelas  after  a  lapse  of  seven  or  eight  days  from  the  ter- 
mination of  the  first  attack,  and  in  the  part  previously  affected,  is 
rarely  so  violent  as  at  first,  being  of  shorter  duration,  and,  in  some 
cases,  only  ephemeral. 

Relapse  should  not  be  confounded  with  the  new  diseases  which 
sometimes  attack  the  convalescent,  nor  with  recurrence. 

The  latter  is  occasioned  sometimes  by  a  peculiar  predisposi- 
tion, and  sometimes  by  a  fresh  exposure  to  the  occasional  or  spe- 
cific causes  of  the  disease.  So  great  is  the  tendency  of  rheumatism 
to  recur,  that  but  few  cases  have  been  cited  of  persons  who  have 
suffered  but  once  in  their  lives  from  this  disease ;  the  recurrence 
in  such  cases  appears  to  be  owing  to  predisposition.  So  with 
erysipelas  of  the  face,  which  frequently  reappears  in  some  individ- 
uals at  longer  or  shorter,  and  sometimes  determinate,  intervals, 
many  examples  of  which  are  related  by  Lorry  and  Franck.  The 
case  is  otherwise  in  the  yearly  recurrences  of  intermittent  fevers  in 
marshy  places ;  these  are  owing  to  a  fresh  exposure  to  the  specific 
cause  of  the  disease. 

The  affections  in  which  relapse  never  occurs,  are  also  exempt 
from  recurrence,  with  some  few  exceptions ;  yellow  fever  and 
typhus,  for  example,  are  never  developed  twice  in  succession,  but 
may  reappear  after  a  greater  or  less  period.  In  rheumatic  affec- 
tions, relapse  is,  perhaps,  less  frequent  than  recurrence. 

The  symptoms  of  recurrence  present  nothing  remarkable  ;  they 
are  not  constantly  more  violent,  or  lighter,  than  in  the  primary 
affection.  A  second,  a  third  pneumonia  is  sometimes  more  violent 
than  the  first ;  but  the  contrary  is  often  observed.  We  saw  a  man 
at  La  Charite,  who  was  suffering  from  peripneumonia  for  the 
tenth  time;  the  first  inflammation  had  been  severer  than  those 
that  followed.  In  the  first  attack  of  erysipelas  of  the  face  this  dis- 
ease has  been  so  violent  as  to  endanger  the  patient's  life,  after- 
23 


266  GENERA,    SPECIES    AND 

wards  diminishing  in  severity  in  proportion  to  the  number  of  times 
it  reappeared,  becoming  at  last  so  slight  as  to  produce  but  little 
functional  disturbance,  and  to  last  but  a  short  time.  What  we 
have  said  of  erysipelas,  equally  applies  to  many  other  diseases, 
particularly  angina  tonsillaris.  —  O. 


CHAPTER  XIY. 


THE  number  of  diseases  to  which  man  is  liable  is  very  great, 
and  would  be  infinite,  if  we  considered,  as  distinct  diseases,  the  in- 
numerable varieties  of  the  same  disease  that  come  under  our  obser- 
vation. The  same  affection  is,  perhaps,  never  presented  twice 
under  the  same  form. 

If  facts  had  been  considered  isolated  from  each  other,  and  those 
among  them  which  are  analogous  had  not  been  distinguished, 
science  would  never  have  existed.  The  relation  of  facts  to  each 
other,  the  resemblance  observed  between  many  of  them,  and  their 
union  under  a  common  name,  indicate  the  commencement  of  med- 
ical science,  and  it  is  only  at  this  stage  that  we  can  arrive  at  any 
knowledge  of  the  course  of  diseases  and  the  means  of  treating  them 
with  success. 

It  is  natural  to  suppose  that  the  genera  of  diseases  recognized 
by  the  earliest  observers,  were  very  different  from  those  of  the 
present  day,  particularly  as  regards  internal  diseases.  Doubtless 
they  often  mistook  the  symptom  for  the  disease,  considering  as  dif- 
ferent affections  what  are  merely  different  phases  of  the  same 
affection,  and  confounding  under  the  same  denomination  diseases 
totally  distinct  in  their  nature. 

In  proportion,  however,  as  physicians  have  become  enlightened 
by  experience  and  observation,  numerous  modifications  have  been 
successively  made  of  the  genera  originally  admitted.  Considered 
merely  in  this  aspect,  the  study  of  pathological  anatomy  has  ef- 
fected an  entire  revolution  in  medicine.  Physicians  of  the  present 
day,  however,  are  far  from  having  arrived  at  the  same  conclusion 
with  regard  to  the  genera  of  diseases,  and  in  fact  have  not  even 
attempted  to  establish  principles  upon  which  this  division  can  be 
founded.  We  shall  endeavor  to  supply  this  deficiency. 

Among  diseases,  there  are  those  that  consist  in  a  material  and 
perceptible  lesion  of  the  solids  or  fluids  that  enter  into  the  compo- 
sition of  the  human  body ;  there  are  others  in  which  we  can  dis- 
cover no  perceptible  alteration,  and  still  a  third  class  in  which 
there  are  only  variable  lesions. 

Well  defined  lesions  of  an  organ,  as  a  fracture  of  a  bone,  a 
wound  of  an  integument,  a  burn,  etc.,  constitute  diseases  of  a  well 


VARIETIES    OF   DISEASE.  267 

marked  character.  The  same  remark  may  be  made  with  regard 
to  some  other  lesions,  the  development  of  which  is  spontaneous, 
such  as  inflammations,  cancer,  tubercles,  etc.  It  is  true,  that  in 
each  of  these  affections  the  material  lesion  is  not  precisely  the  same 
in  every  stage  of  the  disease,  but  the  changes  which  it  undergoes 
are  the  same,  and  repeated  observation  only  proves  their  regular 
succession  and  invariable  connection.  The  redness  of  skin,  which 
marks  the  commencement  of  many  of  the  eruptive  diseases,  is  a 
very  different  lesion  from  the  pustules  that  are  developed  at  a 
later  period,  and  these  differ  no  less,  in  their  turn,  from  the  thick 
crusts  by  which  they  are  succeeded.  Here,  however,  and  still 
more  clearly  than  before,  there  is  but  one  disease.  In  typhoid 
fever,  the  anatomical  lesions  are  different  in  each  of  the  three 
periods  of  the  disease.  At  its  commencement  the  patches  are  hard 
or  soft,  prominent,  and  of  a  rosy  white  color ;  afterwards  eschars 
and  ulcerations  make  their  appearance,  and  still  later  in  the  pro- 
gress of  the  disease,  the  surface  of  these  ulcers  becomes  clean, 
their  edges  become  depressed,  and  they  cicatrize  and  present  a  slate 
color.  Here,  again,  there  is  but  one  disease,  because  these  lesions 
depend  upon  one  cause,  and  succeed  each  other  in  a  determinate 
order. 

The  presence  of  foreign  bodies  in  the  interior  of  the  organs, 
whether  inanimate,  as  calculi  of  different  kinds,  or  living,  as 
cysts  which  participate  in  the  general  vitality,  or  parasitical  ani- 
mals, which  have  an  entirely  independent  existence,  constitutes 
many  distinct  genera  of  disease. 

Collections  of  fluid  in  the  interior  of  the  organs,  attended  with  no 
perceptible  lesion  of  the  solid  tissues,  form  well  denned  genera  of 
disease.  Such  are  the  effusions  of  serum  and  blood  in  the  serous 
membranes  and  the  cellular  tissue.  These  effusions,  it  is  true, 
often  follow  lesions  of  the  solids,  but  since  the  accumulation  is 
oftentimes  the  only  material  alteration  which  is  perceptible,  the 
accumulation  must  in  such  cases  constitute  the  disease.  The  same 
remark  extends  to  those  cases  in  which  certain  fluids  are  excreted 
in  excessive  quantities,  and  often  with  some  change  in  their  quali- 
ties, as,  for  example,  the  urine  in  diabetes  and  Bright' s  disease. 
In  certain  haemorrhages,  the  effusion  of  blood  from  the  vessels 
which  naturally  retain  it,  is  equally  a  single  perceptible  lesion. 

Sanguineous  plethora  and  anemia  may  also  be  classed  among 
diseases  in  which  there  exists  a  material  .perceptible  lesion.  The 
diminution  in  the  quantity  of  the  blood  in  anemia  has  been  meas- 
ured with  great  exactness,  and  its  increase  in  cases  where  there 
are  symptoms  of  general  plethora  can  hardly  be  called  in  question. 

Diseases  arising  from  specific  causes  form  also  distinct  genera. 
The  sting  of  the  bee,  the  cutaneous  affection  that  follows  contact 
with  the  nettle,  the  bite  of  the  viper,  the  virus  of  variola,  vaccinia, 
rubeola  and  scarlatina,  syphilis  and  glanders,  and  poisons  of  every 
kind,  give  rise  to  a  distinct  class  of  affections,  in  which  the  mate- 
rial lesion,  whatever  it  may  be,  is  only  a  secondary  phenomenon. 
It  is.  in  fact,  in  these  cases,  the  cause  that  constitutes  the  disease. 


268  GENERA,    SPECIES   AND 

Intermittent  fevers,  in  the  production  of  which  malaria  plays  so 
important  a  part,  are,  as  a  general  rule,  a  well  defined  class  of  dis- 
eases. If  their  symptoms,  type,  and  the  specific  action  of  quinine 
in  their  treatment,  evidently  distinguish  them  from  other  diseases, 
should  we  not  refer  this  resemblance  of  their  phenomena  to  the 
identity  of  their  cause  7 

With  regard  to  those  diseases  in  which  there  is  no  material 
lesion  of  the  organs,  and  which  arise  from  no  specific  cause,  as  the 
nervous  diseases,  we  can  only  establish  their  genera  from  an  exam- 
ination of  their  symptoms.  Upon  this  subject  the  greatest  differ- 
ence of  opinion  has  existed  among  physicians  down  to  the  present 
time,  and  we  cannot  safely  form  conclusions  in  regard  to  it,  until 
we  have  a  more  thorough  knowledge  of  the  causes  which  produce 
these  affections  and  the  lesions  of  which  they  consist.  A  great 
number  of  them  have  already  been  found  to  be  connected  with 
organic  lesions  upon  the  existence  of  which  they  evidently  depend. 

But  whatever  the  genus  of  a  disease  may  be,  it  is  not  always 
developed  with  the  same  symptoms,  attended  with  the  same  suc- 
cession of  phenomena,  protracted  to  the  same  duration,  or  inclined 
to  the  same  termination.  Variola,  for  example,  is  always  accom- 
panied by  an  eruption  sid  generis,  which  cannot  be  mistaken ;  but 
the  general  phenomena  of  this  affection,  and  the  number  and  form 
of  the  pustules,  are  exceedingly  various.  In  one  case,  the  pulse  is 
full,  the  temperature  of  the  body  increased,  the  pustules  round, 
distended  and  surrounded  by  a  red  areola;  in  another,  on  the 
contrary,  the  pulse  is  feeble,  the  skin  almost  cold,  the  eruptions 
feeble,  of  a  brownish  color,  and  with  a  pale  or  livid  areola.  In 
some  cases,  the  eruption  is  rare  and  scattered  nearly  uniformly 
over  the  whole  skin  ;  in  others,  the  pustules  run  together  over  the 
whole,  or  are  collected  in  great  numbers  on  some  part,  of  the  body. 
Sometimes  the  disease  is  attended  with  no  danger ;  at  other  times 
the  danger  is  imminent,  and  in  a  third  class  of  cases  death  is  almost 
inevitable.  Now  would  it  be  possible  to  acquire  a  correct  idea  of 
variola  by  studying  it  only  under  one  of  the  numerous  forms 
which  it  assumes?  Undoubtedly  not;  and  we  may  apply  the 
same  remark  to  the  study  of  every  disease. 

It  is  then  essential  in  pathology  to  understand  thoroughly  the 
different  modifications  of  each  disease.  These  modifications,  how- 
ever, are  not  all  equally  important.  Some  of  them  are  so  slight 
that  they  may  be  entirely  disregarded,  while  others,  it  is  useful, 
and  even  indispensable,  to  distinguish.  These  latter  have  been 
divided  into  two  classes ;  in  the  first  class  have  been  placed  those 
of,  apparently,  a  greater,  and  in  the  second,  those  of  a  less,  degree 
of  importance.  To  the  former  class  the  term  species  has  been  ap- 
plied, and  to  the  latter,  the  term  varieties,  although  even  at  the  pres- 
ent day  no  fixed  rule  has  been  established  for  distinguishing  the  one 
from  the  other.  The  word  species  has  not  the  same  signification 
in  pathology,  as  in  botany  and  zoology.  In  these  sciences,  it 
designates  the  assemblage  or  class  of  individuals  that  perpetuate 
themselves  by  reproduction ;  while  the  word  varieties  comprises 


VARIETIES    OF    DISEASE.  269 

those  individuals  which,  though  differing  somewhat  in  appearance, 
can  reproduce,  under  given  circumstances,  individuals  resembling 
those  from  which  the  variety  derives  its  origin.  In  pathology,  the 
word  species  expresses  a  mere  abstraction.  Its  distinction  is  so 
vague  and  indefinite,  that  some  have  admitted  twice,  and  even 
four  times,  the  number  that  have  been  admitted  by  others.  Sau- 
vages  carries  the  number  as  high  as  eighteen  hundred ;  Sagar,  to 
two  thousand  five  hundred;  while  Cullen  admitted  only  six  hun- 
dred. There  is  hardly  an  instance,  as  Bayle  *  has  remarked,  in 
which  the  same  author  has  published  several  editions  of  his  works 
without  modifying,  in  some  respects,  the  species  that  he  had  for- 
merly admitted. 

If  it  is  impossible,  as  we  have  reason  to  believe  it  is,  after  the 
fruitless  efforts  of  nosologists,  to  obtain  a  definition  of  species 
which  shall  be  a  uniform  rule  applicable  to  all  diseases,  we  should, 
nevertheless,  in  making  such  a  distinction  as  we  can,  have  regard 
to  the  objects  of  the  greatest  utility,  and  determine  the  species  of 
the  disease  from  the  circumstances  that  exercise  the  greatest  in- 
fluence on  its  treatment.  In  all  the  acute  phlegmasice,  there  is, 
according  to  us,  the  inflammatory,  bilious,  adynamic  and  ataxic 
character,  which  ought  to  determine  their  species,  because  the 
character  of  a  disease,  considered  with  reference  to  its  treatment, 
is  as  important  as,  and  sometimes  more  so  than,  its  genus.  What- 
ever the  genus  of  a  disease  may  be,  if  it  is  attended  with  the  gen- 
eral symptoms  of  inflammatory  fever,  we  resort  to  blood-letting 
and  the  antiphlogistic  regimen;  if  it  has  an  adynamic  character, 
we  must  have  recourse  to  stimulants  and  tonics  ;  if  it  is  legitimate, 
that  is  to  say,  if  it  is  accompanied  with  the  general  phenomena, 
only,  which  are  peculiar  to  it,  without  any  of  the  features  which 
characterize  inflammatory  or  adynamic  fevers,  &c.,  repose  and 
a  slender  diet  are  most  generally  the  only  conditions  necessary  to 
its  cure :  even  these  are  not  always  indispensable,  as  in  some  cases 
of  erysipelas,  chronic  catarrh,  etc.  The  division  of  the  inflam- 
mations into  the  acute  and  chronic  species  is  no  less  important,- 
considered  with  reference  to  their  treatment,  than  the  preceding. 
With  regard  to  haemorrhages,  their  division  into  two  species,  the 
active  and  passive,  has  the  advantage  of  the  same  practical  char- 
acter; but  since  there  are  many  haemorrhages  that  belong  to  neither 
of  these  species,  it  is  necessary  to  recognize  a  third  species  which 
can  hardly  be  confounded  with  the  others.  This  division  is  also 
applicable  to  fluxes,  effusions,  and  particularly  dropsy,  and  may  be 
extended  with  advantage  to  certain  nervous  affections.  The 
happy  effect  of  tonics,  which  have  been  used  for  a  long  time,  seem 
sufficient  to  prove  the  existence  of  passive  neurosis ;  and  the 
extraordinary  cures  that  have  been  effected  in  other  cases  by  a 
totally  opposite  course  of  treatment,  in  addition  to  other  circum- 
stances, would  induce  us  to  recognise  the  existence  of  active  neu- 

*  Theses  de.la  Faculti,  Annee,  1801,  No.  71. 
23* 


270  COMPLICATIONS. 

rosis.  There  are,  doubtless,  cases,  however,  which  belong  to 
neither  of  these  two  classes. 

The  modifications  that  take  place  in  the  symptoms  of  those 
diseases  termed  organic,  with  the  consequent  changes  of  treatment, 
are  unimportant,  and  constitute  rather  varieties  than  species  unless 
they  are  connected  with  some  peculiar  diathesis,  as  a  scrofulous, 
scorbutic  or  syphilitic  taint.^ 

Varieties  of  disease  are  the  result  of  a  multitude  of  circumstan- 
ces some  of  which  are  of  practical  importance,  as,  for  example, 
the  general  severity  of  the  disease,  the  predominance  of  any  par- 
ticular symptom,  or  the  appearance  of  any  remarkable  epiphenom- 
enon,  and  also  the  various  peculiarities  relative  to  seat,  extent, 
cause,  type,  etc.  The  number  and  form  of  the  pustules  in  variola, 
the  seat  of  the  exanthema  in  erysipelas,  the  severity  of  the  pain 
in  pleuropneumonia  or  of  the  delirium  in  typhoid  fever,  constitute 
varieties.  The  same  may  be  said  of  the  continuous  or  remittent 
progress  of  continuous  diseases ;  of  the  quotidian,  tertian  or  quar- 
tan type  of  periodic  diseases,  etc.  We  recognise  varieties,  also,  in 
diseases  according  as  they  arise  from  external  causes,  or  are  pro- 
duced by  an  internal  disposition,  as  they  are  fixed  or  movable,  as 
they  affect  external  or  internal  parts,  the  limbs  and  trunk,  or  the 
organs  more  or  less  essential  to  life.  Varieties  of  diseases  are 
sometimes  referable,  also,  to  the  manner  in  which  they  terminate, 
to  their  regular  or  irregular  return,  etc.,  and  they  frequently  result 
from  complication.  —  O. 


CHAPTER     XV. 

COMPLICATIONS. 

THE  word  complication,  in  its  most  extended  meaning,  expresses 
the  mingling  together  of  many  different  things,  of  which  it  may 
be  important  to  ascertain  the  presence  and  determine  the  nature. 
In  pathology,  we  understand  by  complication,  the  concurrence  or 
simultaneous  existence  of  many  diseases  capable  of  exerting  a 
mutual  influence  on  each  other.  The  coexistence  of  many  entirely 
independent  diseases,  as,  for  example,  cataract,  calculus  in  the 
bladder,  and  an  external  injury,  is  not  a  complication.  Some  phy- 
sicians f  have  proposed  to  limit  still  farther  the  meaning  of  this 

*  The  division  of  diseases  into  false  (morbi  spurii,  nothi),  and  true  (morbi 
exquisite,  legilimi),  has  been  properly  rejected  by  physicians  of  the  present  day. 
The  classification  into  these  species  has  been  entirely  exploded  by  recent  nosology. 

fFernel  and  Plempius,  two  physicians  of  the  sixteenth  and  seventeenth  cen- 
turies, divided  diseases  into  solitary  and  multiple  (morbi  solitarii  et  multiplices}. 
They  subdivided  solitary  diseases  into  simple  and  compound.  They  termed  a 
disease  simple,  which  affects  one  or  more  parts  of  the  body  in  the  same  manner  ; 
as,  for  example,  pneumonia  confined  to  a  single  viscus,  and  gout  which  attacks  at 


COMPLICATIONS.  271 

word,  and  to  apply  it  only  to  diseases  which  exist  simultaneously 
in  the  same  organ,  and  concurrently  produce  a  disturbance  of  the 
same  function ;  but  their  opinion  does  not  carry  with  it  the  weight 
of  authority. 

Some  authors  have  fancied  that  they  traced  the  influence  of 
complication  even  in  the  most  trifling  cases  of  disease,  while  others 
have  been  almost  wholly  unwilling  to  recognize  its  existence.  It 
becomes  important,  then,  to  establish  some  principles  by  which  we 
may  be  guided  with  regard  to  a  subject,  which,  though  not  of  the 
greatest  importance,  is  certainly  not  destitute  of  interest. 

1.  The  simultaneous  development  or  consecutive  extension  of  the 
same  disease,  of  a  phlegmasia,  for  example,  or  an  organic  lesion 
in  continuous  or  contiguous  parts,  is  not  sufficient  to  constitute  a 
complication.     The  simultaneous  inflammation  of  the  pleura,  the 
parenchyma  of  the  lungs  and  the  bronchial  membrane,  is  obviously 
the  extension  of  one  disease  to  different  tissues,  and  not  three 
diseases.     So  in  surgery,  the  injury  of  the  integuments  that  cover 
the  seat  of  a  fracture  is  never  regarded  as  a  complication.     A 
cancerous  affection  of  the  pyloric  extremity  of  the  stomach  is  also 
a  simple  disease,  although  the  disease  extends  to  the  lymphatic 
glands,  the  epiploon,  the  pancreas  or  the  liver. 

2.  The  simultaneous  existence  of  similar  lesions  in  organs,  more 
or  less  remotely  situated  from  each  other,  does  not  constitute  a 
complication,    when   these   lesions  result  from  the   same  cause. 
Thus  the  tubercular  or  cancerous  affection  of  different  organs  in 
different  parts  of  the  economy  is  a  simple  disease,  because  one 
cause,  however  latent,  has  given  rise  to  these  multiple  lesions. 

3.  The  simultaneous  existence  in  different  parts  of  the  body  of 
lesions  differing  entirely  from  each  other,  is  insufficient  to  constitute 
a  complication,  when  these  lesions  are  owing  to  the  influence  of 
one  ascertained  cause.     We  may  mention,  as  examples  of  this,  the 
sore  throat  which  sometimes  accompanies  variola,  the  swelling  of 
the  lymphatic  glands  of  the  neck  incases  of  tinea,  and  the  develop- 
ment of  ulcers,  excrescences,   exostoses  and  buboes,  in  cases  of 
syphilis. 

4.  Neither  is  a  complication  the  coexistence  of  two  diseases, 
one  of  which  is  a  necessary  consequence  of  the  other.     Of  this 

the  same  time  different  articulations,  but  which  arises  from  one  cause,  and  is  fol- 
lowed by  the  same  results.  They  termed  those  diseases  compound  which,  though 
possessing  the  characteristics  of  single  diseases,  arise  from  a  concurrence  of  dif- 
ferent causes  ;  such  are  the  adynamic  or  bilious  phlegmasiae. 

They  recognized  three  sorts  of  multiple  diseases.  1.  Complicated  diseases, 
(morbi  impliciti^  complicati),  those  that  exist  at  the  same  time  in  the  same  organ, 
and  concurrently  produce  a  disturbance  in  the  same  function,  as,  for  example, 
pneumonia  and  phthisis.  2.  Connected  diseases  (morbi  connexi  v el  consequentes} , 
those  cases  in  which  one  disease  concurs  in  the  production  of  another  ;  such  are 
peritonitis  accompanying  inflammation  of  the  uteius,  and  gangrene  developed  in 
the  integuments  in  severe  cases  of  fever.  3.  Distinct  or  separate  diseases  (morbi 
disjuncti  vel  separati),  those  that  do  not  affect  the  same  function,  and  exert  no  in- 
fluence in  the  production  of  each  other;  two  wounds,  one  of  the  thigh,  the  other 
of  the  head,  the  simultaneous  existence  of  gout  in  the  feet  and  hpoma  in  the 
thorax,  or  of  ulcers  in  the  leg  and  pneumonia,  are  obvious  examples. 


272  COMPLICATIONS. 

class  of  cases  is  peritonitis,  resulting  from  a  perforation  of  the 
intestines  or  stomach,  and  rarer  examples  of  it  are  those  cases  of 
pleurisy  which  follow  the  ulceration  of  the  pleura  in  consequence 
of  the  softening  of  a  pulmonary  tubercle. 

5.  Lastly,  the  general  phenomena  that  accompany  the  affection 
of  certain  organs,  do  not  constitute  a  complication.  In  cases  of 
this  sort  there  is  but  one  affection,  although  the  general  disposition 
of  the  patient  gives  the  local  disease  a  peculiar  modification,  as 
for  example,  in  bilious  or  adynamic  pneumonia. 

It  follows,  in  the  first  place,  that  a  complication  cannot  exist 
except  when  there  is  a  coexistence  of  diseases  entirely  distinct  from 
each  other,  either  as  regards  their  origin  and  the  mode  of  treatment 
proper  for  their  cure,  or  their  seat  and  the  anatomical  lesions  of 
which  they  consist ;  and,  in  the  second  place,  it  is  also  a  necessary 
condition,  as  we  have  before  remarked,  that  these  diseases  be  not 
entirely  independent,  but  capable  of  exerting  a  mutual  influence 
on  each  other. 

The  number  of  diseases  that  may  exist  at  once  in  the  same  in- 
dividual and  form  a  complication  is  unlimited.  It  is  rare,  how- 
ever, to  see  more  than  two.  We  sometimes  meet  with  cases  where 
an  individual  is  affected  with  five  or  six  different  diseases ;  but 
these  cases  are  very  uncommon,  and,  besides,  in  a  greater  part  of 
them  the  diseases  have  an  entirely  independent  existence,  and  con- 
sequently come  under  the  head  of  coexistence,  and  not  of  compli- 
cation. 

The  causes  of  complication  are  very  various.  Sometimes  each 
disease  arises  from  a  specific  cause,  as  in  a  complication  of  two 
eruptive  fevers.  Sometimes  the  same  occasional  cause  develops 
two  distinct  affections.  Thus,  the  effect  of  cold  may  give  rise,  in 
the  same  individual,  to  a  rheumatic  affection  and  a  pulmonary 
catarrh,  although,  in  cases  of  this  sort,  there  is  reason  to  suspect 
the  concurrent  influence  of  predisposition.  Complications  are  not 
equally  common  in  all  conditions  of  life.  They  appear  to  be  of 
more  frequent  occurrence  in  infancy  and  mature  age,  than  during 
the  intermediate  period,  and  in  the  inhabitants  of  cities,  rather 
than  those  of  the  country. 

The  most  important  point  to  consider,  in  the  examination  of  this 
subject,  is  the  influence  which  complicated  diseases  exercise  on 
each  other.  In  some  cases,  the  supervening  disease  diminishes 
or  increases  the  severity  of  the  primary  affection,  and  in  others 
has  the  speedy  effect  of,  either  temporarily  or  permanently,  sus- 
pending its  symptoms.  Acute  diseases  are  sometimes  observed 
to  affect  in  this  manner  chronic  complaints,  to  arrest  which,  all 
the  resources  of  art  have  been  in  vain  resorted  to.  Incipient 
variola  has  been  known  to  be  suspended  by  the  development  of 
rubeola  and  on  the  termination  of  the  latter,  to  make  its  reappear- 
ance. A  visceral  phlegmasia  that  follows  an  injury  almost  inva- 
riably modifies  the  symptoms  of  the  external  wound,  and  the  nature 
of  the  fluid  which  it  exhales.  Erysipelas,  which  is  developed  in 
osdematous  limbs,  often  terminates  in  the  suppuration  of  the  cellular 


DIAGNOSIS.  273 

tissue  and  the  gangrene  of  the  integuments.  In  another  class  of 
cases,  the  supervening  disease  does  not  influence  the  one  that 
precedes  it  but  is  influenced  by  it.  Examples  of  this  are  cases  of 
accidental  wounds  and  fractures  in  persons  afflicted  with  scurvy. 
The  scorbutic  affection  undergoes  no  perceptible  change,  but  the 
fractures  do  not  unite,  and  the  wounds  assume  the  appearance 
peculiar  to  scorbutic  ulcers. 

We  conclude,  that  wherever  many  diseases  exist  simultane- 
ously; 1.  they  may  either  have  no  influence  upon  each  other;  2. 
the  second  disease  may  modify,  suspend  or  terminate  the  first ;  or 
3.  the  first,  may  aggravate  the  character  of  the  supervening,  dis- 
ease. —  O. 


CHAPTER  XVI. 

DIAGNOSIS, 

DIAGNOSIS*  is  that  part  of  pathology  whose  object  is  the  discrim- 
ination of  diseases.  To  discriminate  a  disease  is  to  recognize  it 
whenever  it  exists,  whatever  be  the  form  it  assumes ;  and  also  to 
decide  that  it  does  not  exist,  whenever  other  diseases  appear  with 
symptoms  similar  to  its  own. 

"  The  science  of  diagnosis  "  says  Louis,  in  his  Memoir  upon 
fungous  tumors  of  the  dura  mater,  "  is  the  most  important,  most 
useful,  and  most  difficult  of  all  the  divisions  of  medical  science. 
The  discrimination  of  the  peculiar  nature  of  each  kind  of  disease, 
and  of  its  different  species,  is  the  source  of  curative  indications. 
Without  an  accurate  and  precise  diagnosis,  theory  is  ever  at  fault 
and  practice  often  unfaithful." 

There  are  two  different  modes  of  considering  diagnosis  ;  succes- 
sively, in  single  diseases,  or  by  abstraction  of  particular  cases,  as 
a  branch  of  general  pathology.  The  latter  only  will  occupy  us  at 
this  time ;  the  former  belongs  to  the  special  description  of  disease. 

Diagnosis,  thus  generally  considered,  presents  many  points  of 
importance;  of  these  the  principal  are,  1.  the  signs  upon  which 
it  should  be  founded  ;  2.  the  conditions  necessary  for  its  formation, 
both  on  the  part  of  the  patient  and  the  physician ;  3.  the  proper 
mode  of  examination  and  interrogation  of  the  sick,  in  order  to 
acquire  a  knowledge  of  the  affections  under  which  they  labor ;  4. 
the  component  elements  of  diagnosis,  viz.  the  seat  and  nature  of  ana- 
tomical lesions,  and  the  form  and  type  of  symptomatic  phenomena  ; 
5.  the  circumstances  rendering  diagnosis  difficult  or  uncertain. 

§  I.  Diagnostic  Signs.  —  The  term  diagnostic  signs  comprises 

*  Jidyvooig,  discernment;  <Jia,  through  (thoroughly,)  yivuxTxto,  to  know. 


274  DIAGNOSIS. 

all  those  circumstances  which  enlighten  us  in  regard  to  the  genus 
or  species  of  a  disease ;  the  principal  are,  past  or  present  symp- 
toms, the  predisposing  or  determining  causes  of  the  disease,  its 
mode  of  access  and  progress  up  to  the  moment  of  examination,  and 
the  effect  of  remedial  measures.  Diagnostic  signs  are  not  all  of 
equal  importance ;  those  termed  characteristic,  are  such  as  either 
alone,  or  united,  are  sufficient  for  the  recognition  of  the  disease  ;  for 
example,  the  sense  of  tension,  pain  in  the  abdomen,  vomiting, 
etc.,  attending  peritoneal  inflammation.  These  signs  have  also 
been  called  true,  essential,  sufficient,  univocal,  because  they  leave 
no  doubt  in  regard  to  the  existence  of  the  disease.  Among  these 
latter  signs  there  are  some  known  as  pathognomonic*  it  being 
affirmed  that  the  disease  never  exists  without  them,  and  that  they 
are  never  present  except  the  disease  exist.  Characteristic,  differ 
from  pathognomonic,  signs,  in  this  respect,  that  the  disease  may  be 
manifested  without  the  former,  but  never  without  the  latter.  But, 
as  has  been  correctly  remarked,  if  the  term  pathognomonic  be  em- 
ployed in  so  rigorous  a  sense,  no  sign  would  deserve  the  appella- 
tion. The  mobility  of  the  fragments  in  fracture  of  the  bones,  and 
the  flow  of  blood  in  hemorrhage,  are  not  pathognomonic  signs, 
because  both  fracture  and  haemorrhage  may  occur  without  these 
symptoms.  For  this  reason  most  modern  authors  have  employed 
the  terms  pathognomonic  and  characteristic  without  any  distinction, 
to  designate  the  signs  clearly  indicating  the  existence  of  disease. 
Other  signs,  known  as  common,  equivocal,  insufficient,  are  those 
met  with  in  many  diseases,  but  appertaining  especially  to  none ; 
such  are  frequency  of  the  pulse,  elevation  of  temperature  and 
thirst.  These  signs  are  not  indifferent  in  diagnosis,  but  are  less 
important  than  the  preceding. 

The  signs  perceived  by  the  physician's  own  senses  have  an  en- 
tirely different  value  from  those  derived  from  the  account  of  the 
patient  and  his  attendants.  It  is  mainly  by  the  aid  of  the  former 
that  he  should  form  his  opinion  ;  the  latter  will  often  mislead  him 
if  he  yield  them  his  entire  confidence. 

Finally,  there  are  positive  and  negative  signs  in  disease,  that  is, 
the  absence  of  certain  phenomena  and  the  existence  of  others,  may 
concur  in  deciding  the  physician's  opinion.  Negative  signs,  how- 
ever, are  of  far  less  value  than  those  which  are  positive ;  thus,  fine 
and  dry  crepitus,  sanguinolent  sputa,  vomiting  of  dark  colored 
matters  and  epigastric  tumor,  are  signs  of  pneumonia  and  cancer 
of  the  stomach ;  the  absence  of  these  signs  does  not  prove  that  the 
lung  is  not  inflamed,  nor  that  the  stomach  is  free  from  scirrhus. 

We  consider  it  needless  to  enlarge  farther  upon  the  diagnostic 
signs  of  diseases ;  it  has  already  been  our  duty  in  various  parts  of 
this  work,  and  particularly  in  the  long  chapter  devoted  to  symp- 
tomatology, to  point  out  the  diagnostic  value  of  very  many;  we 
shall  again  find  it  necessary  to  notice  them  at  a  future  time,  when 
speaking  of  the  different  modes  of  exploration  necessary  for  the 

*  Ilu&og,  disease ;  yvwjuovixoj,  pertaining  to  discrimination  ;  yivoxrxo),  to  know. 


DIAGNOSIS.  275 

formation  of  diagnosis,  of  the  form  and  type  of  symptomatic  phe- 
nomena, or,  finally,  of  the  conditions  which  render  diagnosis  diffi- 
cult. Whatever  we  might  add  in  this  connection  would  belong  to 
the  particular  history  of  disease. 

$  II.  Necessary  Conditions  for  the  Formation  of  Diagnosis 
on  the  part  of  the  Patient  and  Physician.  —  There  are  many 
conditions  on  the  part  of  the  patient,  which,  if  not  indispensable 
in  forming  a  diagnosis,  are,  at  any  rate,  well  suited  to  render  it 
more  easy  and  exact.  The  first  is,  sufficient  intelligence  to 
understand  the  questions  proposed  by  the  physician,  and  to 
answer  them  with  precision.  We  see  how  difficult  it  is  to  form 
a  decided  opinion  in  regard  to  a  patient,  when  his  intellectual  fac- 
ulties are  naturally  obtuse  or  accidentally  disturbed,  when  he  is  too 
young  to  express  himself  verbally,  or  when  we  do  not  understand 
his  language.  Another  important  condition  is  the  absence  of  all 
attempts  at  deception  on  the  part  of  the  patient,  either  by  conceal- 
ing certain  circumstances  relating  to  his  disease,  or  by  stating 
symptoms  which  he  does  not  experience.  There  are  some  patients 
whose  intelligence  is  sufficient,  and  who  do  not  intend  to  deceive 
the  physician,  but  who  render  their  examination  very  embarrass- 
ing by  the  manner  in  which  they  describe  their  sensations  and 
answer  the  questions  proposed  to  them.  Instead  of  simply  stating 
their  sufferings,  and  replying  directly  to  questions,  they  give  their 
opinion  of  the  peculiar  nature  of  their  disease;  one  is  tormented 
by  mucous  discharges,  bile,  the  blood,  or  by  an  acrimonious  state 
of  the  humors;  another  has  irritation,  tension,  or  relaxation  of 
the  nerves,  etc.  It  is  easy  to  conceive  that  when  a  patient  has 
expatiated  for  an  hour  or  more  upon  his  sensations,  constantly 
dwelling  upon  the  biliary  and  mucous  secretions,  the  acrimonies, 
and  the  nerves,  the  physician  will  have  made  no  progress  in  the 
diagnosis.  We  might  suppose  that  by  requesting  patients  not  to 
use  such  language,  but  only  to  tell  what  they  actually  feel,  we 
could  induce  them  to  speak  more  intelligibly;  but  we  are  en- 
tirely mistaken  ;  the  greater  number  do  not  change  their  language 
in  the  least.  The  physician  needs  all  his  patience  to  enable  him 
to  listen  ;  and  in  certain  cases  he  is  obliged  to  form  his  opinion 
solely  by  what  he  sees,  almost  entire  abstraction  being  made  of  all 
that  he  has  heard. 

The  necessary  conditions  for  accurate  diagnosis  on  the  part  of 
the  physician,  are  numerous.  The  first,  and  indispensable  condi- 
tion, is  a  thorough  knowledge  of  pathology.  He  who  is  not  fa- 
miliar with  the  signs  of  all  diseases  is  not  fit  to  give  an  opinion  of 
any  one  in  particular.  Another  condition,  no  less  important  than 
the  theoretical  knowledge  of  disease,  is  long  and  careful  observa- 
tion, and  ability,  by  means  of  frequent  dissections,  to  confirm 
or  rectify  a  diagnosis  made  during  the  progress  of  disease.  The 
physician  who  has  not  for  a  long  time  applied  his  knowledge  at 
the  bedside  and  assisted  at  many  post-mortem  examinations,  is 
certainly  unfit  to  form  a  correct  opinion  of  the  diseases  he  observes. 


276  DIAGNOSIS. 

Supposing  his  diagnosis  to  be  correct  in  some  cases,  it  would  be 
the  opposite  in  a  great  number,  and  in  all,  it  would  be  formed 
slowly  and  doubtfully.  Skill  in  diagnosis,  which  constitutes,  in 
connection  with  a  readiness  to  perceive  indications,  that  quality 
known  as  medical  tact,  can  only  be  acquired  gradually ;  it  implies 
the  union  of  all  the  qualities  necessary  to  the  observer ;  integrity  of 
the  senses,  which  thus  distinctly  transmit  every  modification  of  the 
phenomena  within  their  jurisdiction,  a  firm  and  penetrating  mind, 
capable  of  properly  collating,  comparing  with  discernment,  and  de- 
ducing from  facts  the  inferences  and  consequences  which  they  fur- 
nish, and  which,  uniting  boldness  and  prudence  in  due  propor- 
tions, dares  at  times  to  obey  the  dictates  of  a  seeming  inspiration, 
which  is  really  an  accurate,  although  a  rapid,  appreciation  of  the 
most  expressive  phenomena  of  the  disease.  These  precious  quali- 
ties are  rarely  combined  in  one  individual,  and  the  number  of  phy- 
sicians remarkable  for  great  skill  in  diagnosis  is  always  very 
limited. 

There  is  still  another  condition,  which,  if  not  indispensable,  is  at 
least  of  great  service  to  the  physician  in  the  diagnosis  of  diseases ; 
this  is  a  knowledge  of  the  normal  state  of  the  various  functions  of 
the  patient  to  whom  he  is  called.  The  modifications  made  by  dis- 
ease in  the  physiognomy,  gait,  voice,  mental  disposition,  circula- 
tion and  respiration,  are  often  hardly  appreciable  by  the  physician 
who  has  not  seen  the  patient  when  in  health,  while  they  would 
be  very  manifest  to  him  who  can  make  this  comparison.  On  this 
account  we  must  approve  the  wise  forethought  of  those  persons 
who  wish  to  be  known  during  health  by  the  physician  who  is  to 
attend  them  when  ill.  In  order  to  respond  properly  to  the  confi- 
dence of  these  individuals,  the  physician  should  thoroughly  ex- 
amine the  condition  of  all  the  functions  as  he  would  do  in  one 
.laboring  under  disease. 

Not  only  is  it  necessary  for  the  physician  to  have  exercised  his 
senses  for  the  detection  of  every  modification  of  morbid  phenome- 
na, and  his  mind  in  determining  their  value,  but  he  should  also 
have  acquired  by  practice,  and  as  far  as  possible  by  instruction 
from  others,  the  habit  of  employing  the  different  modes  of  explo- 
ration, by  the  aid  of  which  he  attains  a  knowledge  of  certain 
phenomena,  likely  to  escape  ordinary  observation,  or  at  any  rate, 
to  be  far  less  accurately  appreciated.  These  modes  of  exploration 
are  pressure,  palpation,  touch,  succussion,  mensuration,  percus- 
sion, auscultation,  examination  with  various  kinds  of  sounds,  spec- 
ula, magnifying  glasses,  the  microscope,  and  chemical  reagents. 

1.  Pressure.  Pressure  made  with  the  hands  or  fingers,  and 
which  should  not  be  confounded  with  palpation,  is  doubtless  a 
very  simple  mode  of  exploration,  but  one  that  furnishes,  notwith- 
standing, numerous  and  important  signs.  In  the  first  place,  it 
enables  us  to  recognise  the  various  changes  in  the  resistance  of 
diseased  parts,  as  the  hardness  of  the  cellular  tissue  in  phlegmon - 
ous  inflammation,  the  tension  of  the  abdomen  in  tympanitis,  its 
simple  resistance  in  chronic  peritonitis,  the  elasticity  of  tumors 


DIAGNOSIS.  277 

containing  pus,  the  flaccidity  of  parts  whose  volume  has  rapidly 
diminished,  as  the  abdomen  after  the  employment  of  the  trocar, 
or  after  parturition,  or  that  of  an  inflammatory  tumor  after  the 
natural  or  artificial  evacuation  of  its  purulent  contents. 

When,  by  equable  and  simultaneous  pressure  made  on  both 
sides  of  the  abdomen,  with  both  hands,  and  over  exactly  corres- 
ponding regions,  a  decided  and  constant  difference  is  perceived  in 
regard  to  the  extent  to  which  each  hand  penetrates,  we  should 
suspect  some  deep-seated  lesion  of  the  least  depressible  side  of  the 
abdomen,  even  when  the  hand  does  not  distinguish  any  alteration 
in  the  consistence  of  the  tissues.  It  should  not  be  forgotten  that 
an  abnormal  direction  of  the  dorsal  or  lumbar  portion  of  the  spinal 
column  might  cause  the  same  sensation,  without  furnishing  the 
same  inference. 

When  air  or  serum  is  infiltrated  into  the  subcutaneous  cellular 
tissue,  pressure,  by  displacing  the  infiltrated  fluid,  causes,  first,  a 
sensation  of  crepitation  ;  secondly,  it  conveys  the  impression  of 
penetration  by  the  finger  into  the  compressed  part ;  and  if  two 
fingers  be  used  to  pinch  up  a  fold  of  the  skin,  upon  the  thigh,  for 
instance,  they  approach  each  other,  and  a  transient  pitting  of  the 
infiltrated  part  succeeds  this  action  of  the  fingers.  In  typhoid 
fever,  when  pressure  is  made  in  the  right  iliac  fossa,  a  remarkable 
gurgling  is  produced,  which  occurs  also,  from  similar  pressure,  in 
abscesses  into  which  air  has  penetrated. 

When  a  liquid  is  contained  in  a  cavity  which  has  no  outlet,  and 
whose  parietes  are  elastic,  as  the  knee  or  abdomen,  rapid  pressure 
furnishes  us  with  important  signs ;  the  shock  of  the  patella  against 
the  opposite  surfaces  of  the  femur  and  tibia,  shows  a  synovial 
effusion  which  recedes  before  the  finger.  When  the  abdomen  is 
simultaneously  the  seat  of  moderate  effusion,  without  evident 
fluctuation,  and  of  a  tumor  so  deeply  seated  as  to  be  inaccessible 
to  common  palpation,  we  find  a  valuable  mode  of  exploration,  as 
yet  very  little  known  by  physicians,  in  rapid  pressure  practised 
with  the  extremities  of  the  fingers.  By  means  of  this,  we  discover, 
often  at  considerable  depth,  something  resistant  against  which  the 
abdominal  parietes  strike ;  and  the  sensation  of  a  body  which  re- 
treats before  the  fingers  and  returns  immediately  on  the  cessation  of 
pressure,  indicates  that  there  is  liquid  interposed  between  the 
tumor  and  the  integuments,  the  sound  on  percussion  of  the  abdo- 
men, as  is  noticed  in  these  cases,  being  entirely  flat. 

Pressure,  also,  furnishes  certain  signs  relative  to  the  change  it 
effects  in  the  coloration  of  the  parts. 

Certain  kinds  of  erythema,  are  characterized  by  the  disappear- 
ance of  their  redness  under  the  pressure  of  the  finger,  as  erysipelas, 
scarlatina,  and  roseola ;  others  by  its  persistence,  notwithstanding 
pressure,  or  even  by  its  increase,  as  purpura  hamorrhagica ;  the 
reason  of  this  doubtless  is,  that  the  surrounding  skin  becomes 
whiter  by  pressure,  and  makes  the  darkness  of  the  heemorrhagic 
spot  more  intense  by  contrast. 

In  cases  of  very  slight  rubefaction,  as  that  which  is  diffused 
24 


278  DIAGNOSIS. 

over  the  entire  surface  of  the  body  in  sanguineous  plethora,  or 
around  certain  joints  affected  with  rheumatism,  pressure,  made 
with  a  single  ringer,  causes  a  discoloration  of  the  compressed  point, 
and  renders  the  slight  redness  of  the  neighboring  parts  more  man- 
ifest. 

Finally,  certain  pains,  particularly  those  of  an  inflammatory 
nature,  are  aggravated  by  pressure ;  others  are  not  influenced  by 
it,  as  is  observed  in  some  cases  of  sciatic  neuralgia  ;  the  intensity 
of  others  is  diminished,  as  the  abdominal  pain  of  lead  colic  j  others, 
still,  are  momentarily  suspended  by  strong  pressure  upon  the  af- 
fected point,  as  certain  varieties  of  hemicrania.  Lastly,  entire  ab- 
sence of  sensation  under  pressure  sufficiently  strong  to  give  pain, 
as  that  made  with  the  extremities  of  the  ringers,  or  even  with  the 
nails,  shows  complete  loss  of  sensibility. 

2.  Palpation.  Palpation,  or  the  act  of  feeling,  is  one  of  the 
most  useful  and  most  frequently  employed  means  of  exploration. 
It  consists  in  the  methodical  application  of  the  physician's  hand  to 
the  affected  parts,  for  the  purpose  of  appreciating  the  various  alter- 
ations which  may  have  taken  place.  It  requires  much  circum- 
spection, dexterity  and  practice  united,  in  order  to  derive  from  it 
all  the  advantage  it  possesses,  to  avoid  the  dangers  which  it  some- 
times occasions  and  the  errors  to  which  it  may  give  rise.  The 
following  is  the  best  mode  of  procedure. 

The  parts  upon  which  palpation  is  to  be  practised,  should  be  so 
placed  as  that  their  enveloping  muscles  may  be,  as  nearly  as  pos- 
sible, in  a  state  of  complete  relaxation ;  muscular  contraction 
would  have  the  double  disadvantage  of  withdrawing  the  parts 
from  the  hand  of  the  examiner,  arid  sometimes  even  of  simulating 
tumors,  as  is  particularly  the  case  in  regions  occupied  by  inter- 
secting muscles,  as  the  recti  abdorriinis.  It  is  often  useful  to  vary 
the  attitude  of  the  patients ;  by  a  comparison  of  the  results  Ob- 
tained in  different  positions,  we  complete,  and  sometimes  rectify, 
the  ideas  suggested  by  the  first  examination. 

It  is  generally  preferable  that  the  parts  to  be  examined  should 
be  uncovered :  delicate  linen,  however,  does  not  interfere  with 
palpation,  indeed,  it  often  facilitates  it,  especially  in  sensitive  per- 
sons, in  whom  the  coldness  of  the  hand  employed  in  palpation,  or 
the  disagreeable  sensations  caused  by  exposure  of  the  person, 
excite  involuntary  muscular  contraction,  which  ceases  with  the 
removal  of  its  exciting  cause. 

In  practising  palpation,  the  whole  hand,  or  even  both  hands, 
should  be  used,  according  to  the  extent  of  the  parts,  and  riot  one 
or  more  fingers  only,  except  in  cases  where  the  volume  of  the 
affected  part  will  admit  of  no  other  mode  of  exploration.  Usually, 
the  whole  hand  should  be  at  once  applied  to  the  diseased  part, 
instead  of  pressing  perpendicularly,  or  even  obliquely,  with  the 
extremities  of  the  fingers,  as  is  often  done  by  inexperienced  per- 
sons. We  should  commence  by  palpation  of  the  neighboring 
parts,  or  of  those  similar  in  kind  to  the  one  we  wish  to  examine, 
as  for  example,  the  healthy  limb,  breast,  testicle,  or  side  of  the 


DIAGNOSIS.  279 

abdomen,  previously  to  those  affected,  so  that  we  may,  by  a 
knowledge  of  the  normal  condition,  better  appreciate  the  altera- 
tions, sometimes  slight,  produced  by  disease  in  the  unhealthy 
parts.  The  hand  should  at  first  be  simply  applied  to  these 
parts ;  if  it  encounter  no  resistance  and  produce  no  pain,  we 
should  gradually  exert  more  pressure,  directly,  at  first,  afterwards, 
with  slight  lateral  movements.  When  we  discover  an  enlarge- 
ment or  swelling,  we  should  endeavor  to  circumscribe  it  completely, 
by  surrounding  it  on  all  sides  with  the  fingers,  sufficiently  flexed 
and  separated  from  each  other,  to  be  applied  to  the  whole  of  the 
resisting  or  swollen  surface,  and  thus  ascertain  its  limits.  Fre- 
quently, one  of  the  hands  should  be  so  placed  as  to  favor  the  exam- 
ination which  is  particularly  conducted  by  the  other  :  thus,  in  order 
to  verify  an  obscure  fluctuation,  we  press  back  the  fluid  with  one 
hand  towards  the  place  where  the  other  hand  is  applied :  in  exam- 
inations of  the  abdomen,  one  hand,  applied  to  the  right  lumbar 
region,  pushes  the  liver  forward,  so  that  the  other  hand  can  better 
appreciate  its  volume  and  its  consistence.  Tn  order  that  the  hand 
placed  upon  the  hypogastrium  may  ascertain  the  condition  of  the 
uterus,  it  is  often  requisite  to  raise  the  os  tincse  with  the  index 
finger  of  the  other  hand.  In  the  examination  of  inflammatory 
tumors,  abscess,  certain  species  of  hypertrophy,  various  kinds  of 
organic  degeneration,  and  arterial  aneurism,  palpation  furnishes 
signs  of  peculiar  value,  especially  when  uniformly  identical  results 
are  obtained  on  repeated  trials  at  different  intervals.  It  enables 
us  to  discover  the  number,  size,  form  and  consistence  of  the  above 
tumors,  to  judge  whether  their  surface  be  smooth  or  uneven, 
whether  they  are  soft  or  hard,  and  if  these  qualities  characterize 
them  throughout  or  only  partially ;  whether  they  are  elastic  or 
fluctuating,  unique  or  multiple,  fixed  or  movable :  if  they  exhibit 
internal  movements  or  pulsations ;  if  these  pulsations  be  isochro- 
nous, or  not,  with  those  of  the  heart  or  arteries,  if  they  are  the 
effect  of  simple  displacement,  or  of  an  actual  expansion,  if  they 
may  be  referred  to  that  undulatory  thrill  observed  in  many  dis- 
eases of  the  circulatory  system,  especially  in  certain  alterations  of 
the  cardiac  orifices  and  in  varicose  aneurism,  etc. 

Palpation,  moreover,  repeated  at  suitable  intervals,  enables  the 
physician  to  judge  of  certain  changes  which  time  and  remedies 
effect  in  the  course  of  diseases ;  diminished  or  increased  volume  of 
parts  already  examined  becomes  in  this  way  the  most  certain  of 
signs,  and  is  suggestive  of  the  most  positive  ideas.  We  should, 
however,  remember  that  various  modifications,  taking  place  either 
in  the  situation  of  the  tumor  or  in  the  surrounding  parts,  may 
sometimes  deceive  the  practitioner.  A  cancerous  tumor,  developed 
in  the  greater  curvature  of  the  stomach,  is  more  or  less  apparent 
according  to  the  state  of  vacuity  or  repletion  of  that  viscus,  and 
in  proportion  to  the  amount  of  gas  contained  in  the  neighboring 
intestines.  We  have  so  frequently  observed,  in  cases  of  this  de- 
scription, and  in  others  analogous,  the  difficulty  of  reaching  the 
tumor  lead  to  the  supposition  of  its  decrease,  or  even  its  disap- 


280  DIAGNOSIS. 

pearance,  that  we  have  thought  proper  particularly  to  notice  this 
source  of  error. 

The  simple  changes  wrought  by  disease  in  the  natural  solidity 
of  the  organs,  are,  moreover,  important  phenomena  to  establish, 
and  can  only  be  appreciated  by  means  of  palpation.  Not  to  men- 
tion that  relaxation  of  the  integuments  and  muscles,  which  is,  as 
it  were,  the  first  stage  of  emaciation,  and  which  in  some  instances 
furnishes  us  with  an  important  sign,  we  would  notice  that  cir- 
cumscribed hardness  and  the  consecutive  engorgement  of  a  certain 
portion  of  the  integuments,  where  deep-seated  inflammation  is 
developed,  or  purulent  matter  collected;  finally,  we  would  call  to 
mind  that  resistant  state  of  the  abdomen  so  precious  in  the  diag- 
nosis of  certain  cases  of  chronic  peritonitis. 

3.  Examination  by  the  Touch.  Touch  *  is  a  species  of  palpation 
made  by  one  or  more  of  the  fingers,  introduced  into  parts  naturally 
inaccessible  to  the  eye,  as  the  vagina  and  rectum,  with  the  design 
of  verifying  different  physiological  and  morbid  conditions,  either 
of  these  passages,  or  of  neighboring  organs. 

The  index  finger  of  either  hand  is  usually  the  only  one  employed 
in  vaginal  and  rectal  examinations  ;  it  is  very  rare  that  diagnosis 
is  assisted  by  the  introduction  of  two  fingers  into  the  same  pas- 
sage ;  but  in  some  circumstances,  when  we  wish  to  examine  the 
recto-vaginal  parietes,  we  introduce,  simultaneously,  the  thumb 
into  the  vagina,  and  the  index  finger  of  the  same  hand  into  the  rec- 
tum. The  nail  of  the  finger  which  is  used  in  such  examinations 
should  be  short,  and  smooth,  so  that  the  pulp  of  the  finger  may  be 
more  accurately  applied  to  the  parts,  and  no  pain  or  laceration  be 
produced.  Previously  to  such  an  examination,  the  bladder,  and 
especially  the  rectum,  should  be  evacuated.  These  preliminaries 
being  fulfilled,  and  the  finger  being  covered  with  cerate  or  some 
other  unctuous  or  mucilaginous  substance,  we  proceed  as  follows, 
for  vaginal  and  rectal  examinations. 

If  we  intend  to  examine  the  vagina  and  uterus,  the  woman  may 
be  either  recumbent  or  erect.  If  the  former  position  be  adopted, 
she  should  assume  the  dorsal  decubitus,  the  body  being  somewhat 
inclined  upon  the  pelvis,  so  as  to  relax  the  muscles  as  completely 
as  possible,  the  thighs  being  slightly  separated  and  flexed.  The 
physician  should  stand,  by  preference,  at  the  right  side  of  the  bed, 
so  that  he  may  use  the  index  finger  of  the  right  hand.  If  the  pa- 
tient be  in  the  upright  posture,  she  should  be  requested  to  lean 
upon  some  firm  support,  separating  the  thighs  slightly,  and  the  ex- 
aminer should  be  before  her,  upon  a  low  seat,  or  resting  upon  one 
knee.  Whatever  be  the  position,  we  should  avoid  exposure  of  the 
patient  under  an  examination  more  or  less  trying  to  nearly  all 
females.  With  the  thumb  and  middle  finger  of  the  hand  em- 

*  The  term  "  toucher,"  which  we  have  rendered  by  the  English  word  touch, 
is  used  in  a  medical  sense,  by  the  French,  to  express  explorative  examination  by 
the  finger,  usually,  the  index  finger  of  the  right  hand  ;  in  some  rare  cases,  two 
fingers  are  used,  as  is  mentioned  in  the  text.  The  term  is  employed,  in  the  vast 
majority  of  cases,  to  indicate  vaginal  exploration  with  the  finger.  —  TRANS. 


DIAGNOSIS.  281 

ployed,  we  slightly  separate  the  labia  majora  of  the  vulva,  the 
index  finger  is  readily  introduced  into  the  vagina,  while  the  other 
fingers  are  strongly  flexed  upon  the  palm  of  the  hand.  The  finger 
should  enter  the  vagina  slowly,  in  order  to  avoid  the  pain  which 
might  be  occasioned  by  a  rapid  introduction,  and  to  appreciate 
more  thoroughly  either  the  changes  which  may  be  detected  in  the 
parietes  of  the  passage,  as  regards  heat,  sensibility,  consistence, 
form,  and  moisture,  or,  in  certain  cases,  to  ascertain  the  formation 
of  the  pelvic  cavity.  When  the  finger  has  reached  the  os  tincae, 
which  will  be  recognized  by  its  form,  consistence,  and  by  the 
central  depression  which  distinguishes  its  orifice,  we  ascertain 
if  it  be  in  its  normal  position,  if  depressed  or  inclined  to  the 
right  or  left,  forward,  or  backward ;  the  sensibility,  length  and 
volume  of  the  neck,  whether  it  be  hard,  or  soft,  sometimes  the  in- 
equalities of  its  surface,  the  relative  size  of  the  two  labia  oris 
tineas,  the  degree  of  dilatation  of  its  orifice,  as  well  as  its  form,  ele- 
vation and  direction,  should  each  be  the  objects  of  attentive  exam- 
ination. We  next  proceed  to  the  examination  of  the  uterus.  For 
this  purpose,  raising  the  finger,  as  if  to  elevate  the  organ,  and 
carry  it  backwards,  towards  the  brim  of  the  pelvis,  we  judge  of  its 
weight  and  mobility,  and  if  the  woman  be  pregnant,  we  may  thus 
determine  and  perceive  the  repercussion  (ballottemenf]  of  the  foetus. 
When  the  patient  is  in  a  horizontal  position,  the  unoccupied  hand 
should  be  placed  upon  the  hypogastrium,  in  order  to  appreciate  the 
volume  of  the  uterus,  and  accurately  determine  its  elevation ;  by 
this  means,  we  may,  in  certain  cases  of  abdominal  tumors  of  diffi- 
cult diagnosis,  gain  a  more  accurate  knowledge  of  their  seat  and 
connections ;  by  alternate  pressure  of  the  hand,  applied  to  the  ab- 
domen, and  of  the  finger  resting  upon  the  uterus,  we  can  generally 
ascertain  whether  the  tumor  under  examination  be  formed  by  the 
uterus  itself,  merely  attached  to  it,  or  distinct  from  it. 

In  order  to  derive  all  the  advantage  possible  from  this  mode  of 
exploration,  it  is  often  necessary  to  change  the  position  of  the  pa- 
tients, and  to  place  them  alternately  in  the  horizontal  and  upright 
position.  The  latter  is  particularly  useful  when  we  wish  to  ascer- 
tain with  accuracy  certain  deviations  of  the  uterus,  especially  pro- 
lapsus, or  to  verify  the  phenomenon  of  repercussion  of  the  ifoetus. 

In  all  cases  where  morbid  changes  in  the  vagina,  or  the  neck  of 
the  uterus,  are  discovered  by  the  touch,  the  physician  should  ex- 
amine ocularly,  and  by  the  sense  of  smell,  the  finger  which  has 
been  employed,  in  order  to  judge  of  the  changes  which  may  have 
occurred  in  the  vaginal  mucus,  or  any  other  matters  remaining 
upon  the  finger. 

In  rectal  examinations,  the  horizontal  posture  will  generally  be 
convenient,  the  body  being  inclined  to  one  side,  with  the  corres- 
ponding limb  extended,  the  other  slightly  flexed.  The  index  finger 
should  be  introduced  more  slowly  than  in  vaginal  examinations; 
and  in  case  of  strong  contraction  of  the  sphincter,  we  should  wait 
for  its  relaxation.  Still  greater  caution  is  requisite  when  the  margin 
of  the  anus  is  the  seat  of  hsemorrhoidal  tumors,  or  of  fissure.  The 
24* 


282  DIAGNOSIS. 

finger  thus  introduced  into  the  intestine  should  be  moved  gradually 
over  the  whole  internal  surface,  in  order  to  appreciate  the  various 
modifications  which  may  exist,  in  its  sensibility,  tension,  heat  and 
consistence,  or,  as  regards  any  inequalities  it  may  present,  such  as 
granulations,  wrinkles,  ulcerations,  tumors,  with,  or  without  a  pedi- 
cle, fraena,  strictures,  or  dilatation  of  this  portion  of  the  rectum. 
The  rectal  touch  may  moreover  discover,  in  the  male,  through  the 
recto-vesical  parietes,  calculi,  engaged  in  the  inferior  extremities  of 
the  ureters,  or  occupying  the  base  of  the  bladder,  or  tumefaction 
arid  induration  of  the  prostate,  which  is  a  frequent  cause  of  reten- 
tion of  urine.  In  the  female,  we  may  by  this  means  detect  aug- 
mented volume  of  the  uterus,  its  deviation  from  the  normal  posi- 
tion in  retro  version,  and  certain  fibrous  tumors  developed  in  its 
posterior  parietes,  near  its  external  surface ;  it  also  furnishes  valu- 
able signs  in  certain  forms  of  extra-uterine  pregnancy,  and,  in 
some  very  rare  cases,  reveals  the  absence  of  the  uterus. 

Vaginal  or  rectal  touch  is  also  indispensable  for  the  diagnosis  of 
diseases  which  have  their  seat  in  the  pelvic  cavity,  exteriorly  to 
these  passages  and  the  organs  with  which  they  are  immediately 
connected  ;  such  as  that  kind  of  abscess  which  often  occurs 
after  parturition,  and  scirrhous  tumors  and  exostoses  developed 
within  the  pelvis,  which  would  remain  unknown  in  most  cases,  if 
this  mode  of  exploration  did  not  enable  the  physician  to  seek  for 
and  discover  them. 

The  thorough  exploration  of  the  posterior  fauces,  by  means  of 
the  finger,  may  be  considered  analogous  to  the  above,  its  purpose 
being  to  examine  the  most  remote  portion  of  the  nasal  fossae  above, 
and  the  various  alterations  of  the  epiglottis,  arytenoid  folds,  and 
middle  portion  of  the  pharynx,  below.  This  examination,  in 
which  we  are  sometimes  obliged  to  keep  the  maxillae  separated 
by  means  of  some  resistant  body  placed  between  the  molar  teeth, 
may  suffice  of  itself,  in  some  cases,  to  establish  the  diagnosis  of 
certain  very  obscure  diseases,  as  polypi  developed  in  the  nasal  fos- 
sae, oedema  of  the  glottis,  abscess  and  foreign  bodies  in  the  pharynx. 

In  concluding  our  remarks  upon  this  mode  of  exploration,  we 
deem  it  necesary  to  repeat  an  opinion  daily  expressed  in  our  clini- 
cal lectures,  viz.,  that  this  kind  of  examination  is  too  much  neg- 
lected, that  most  physicians  are  not  aware  how  much  information 
it  supplies,  nor  how  many  errors  may  be  avoided  or  rectified  by  its 
aid ;  and  that  consequently,  it  is  an  imperative  duty  to  have  re- 
course to  it  whenever  any  circumstance  draws  our  attention  to 
those  organs  where  its  application  is  possible. 

4.  Siiccussion.  Succussion  consists  in  shaking  the  patient's 
body  with  sufficient  force  to  agitate  the  fluids  and  gases  contained 
in  one  and  the  same  cavity,  and  to  cause  more  or  less  distinct 
gurgling. 

A  lateral  shock  given  to  the  body,  and  frequently  repeated,  by 
means  of  the  two  hands  placed  upon  the  lower  part  of  the  chest, 
one  on  the  right,  the  other  on  the  left  side,  usually  enables  us  to 
detect  this  species  of  gurgling,  without  the  necessity  of  ausculta- 


DIAGNOSIS.  283 

tion ;  in  most  patients  the  sound  is  sufficiently  distinct  to  be  per- 
ceived at  a  considerable  distance. 

Succussion  is  applicable  to  but  a  small  number  of  diseases.  We 
cannot,  indeed,  produce  the  sound  above-mentioned,  except  in  cases 
where  gas  and  liquids  are  contained  in  the  same  natural  or  acci- 
dental cavity,  and  such  affections  are  rare ;  the  principal  are  hy- 
dro-pneumothorax,  (an  affection  almost  always  consecutive  upon 
the  ulceration  of  pulmonary  tubercles,  with  perforation  of  the 
pleura,)  and  certain  affections  of  the  stomach,  among  which  the 
dilatation  consequent  on  scirrhus  of  the  pylorus  is  the  most  fre- 
quent. In  the  latter  case,  the  gurgling  is  produced  in  the  abdo- 
men ;  in  the  former  it  takes  place  in  the  thorax.  A  fold  of  intes- 
tine, considerably  dilated,  may  also  present  this  phenomenon,  if 
succussion  be  practised.  We  detected  it  upon  one  occasion,  in  a 
cyst  of  the  ovary,  which  contained,  as  was  discovered  at  the  post- 
mortem dissection,  pus  of  creamy  appearance  and  very  fetid  gases, 
which,  as  it  seemed  to  us,  were  probably  produced  by  the  putrefac- 
tion of  this  liquid.  We  should  add  that  there  are  certain  persons, 
whose  digestion  seems  regular,  in  whom  stomachal  gurgling  occurs 
on  succussion,  after  the  ingestion  of  liquid  aliment. 

5.  Mensuration.  Mensuration,  as  the  word  imports,  is  that 
mode  of  examination,  by  which  we  endeavor  to  determine  with 
more  accuracy  than  is  attainable  by  either  sight  or  touch,  the 
volume  or  length  of  certain  diseased,  or  healthy  parts.  For  this 
purpose  we  employ,  according  to  the  form  of  the  parts,  either  an 
inelastic  band,  or  a  pair  of  callipers  (compas  d*  epaisseur),  with  a 
scale  divided  into  centimetres  or  lines ;  in  many  cases,  the  physi- 
cian will  find  his  fingers  the  most  natural  and  available  instrument 
for  mensuration. 

Certain  precautions  are  necessary  in  the  application  of  this 
method  of  exploration,  so  as  to  give  to  its  results  the  accuracy 
which  constitutes  their  utility.  The  first  is  a  uniform  degree  of 
pressure  in  all  the  successive  measurements ;  the  second,  a  like 
uniformity  and  precision  in  regard  to  the  posture  of  the  patient, 
and  particularly  the  position  of  the  parts  to  be  examined :  the 
position  should,  if  possible,  be  rectilinear,  so  that  future  examina- 
tions, made  in  exactly  the  same  manner,  may  accurately  exhibit 
the  alterations,  if  any  have  supervened.  If  mensuration  be  ap- 
plied to  the  head  or  the  thorax,  the  patient  should  be  either  sitting 
or  erect ;  his  posture  should  be  the  horizontal,  when  the  limbs  arid 
abdomen  are  to  be  measured.  Another  point  of  equal  importance 
is  to  apply  the  instruments  upon  exactly  the  same  points ;  the 
nipple  and  the  umbilicus,  in  mensuration  of  the  abdomen  and 
thorax,  may  serve  as  limits  (jalons). 

Mensuration  may  be  very  advantageously  applied  in  diseases 
which  change  the  direction  or  the  relations  of  one  or  more  portions 
of  the  osseous  system.  It  proves  the  existence  of  disorders  which 
the  eye  would  only  lead  us  to  suspect,  and  enables  us  to  determine 
their  extent  and  to  trace  their  changes;  on  this  account  it  is  fre- 
quently employed  by  orthopedic  surgeons.  We  cannot,  however, 


284  DIAGNOSIS. 

too  often  repeat  how  important  it  is  in  these  cases,  as  well  as  in 
moulding  in  plaster,  to  maintain  strict  uniformity  of  attitude,  in 
order  that  each  ulterior  examination  may  be  conducted  under  pre- 
cisely similar  conditions. 

In  estimating  the  length  of  the  lower  limbs,  mensuration  pre- 
sents some  difficulties  with  which  we  should  be  familiar ;  lateral 
inclination  of  the  pelvis  might  erroneously  lead  us  to  suppose  elon- 
gation-or  shortening  of  a  limb,  did  we  not  possess,  in  the  ingenious 
process  proposed  by  Professor  Sanson,  a  sure  means  of  ascertaining 
the  direction  of  the  pelvis,  *  and  consequently  of  rectifying  the 
error. 

More  difficulty  is  encountered  in  mensuration  of  the  chest,  than 
in  that  of  any  other  portion  of  the  body,  on  account  of  its  alter- 
nate movements  of  dilatation  and  contraction  and  its  frequent 
faulty  conformation.  The  object  of  thoracic  mensuration  is,  to 
determine  whether  there  exist  enlargement  or  diminution  in  the 
volume  of  either  side.  The  following  is  the  mode  of  procedure. 

The  patient  should  be  seated,  the  arms  separated  from  the  body, 
and  the  hands  clasped  upon  the  head.  The  spinal  processes  of 
the  dorsal  vertebrae  distinguish  the  median  line  posteriorly;  a  cord 
drawn  from  the  superior  extremity  of  the  sternum  to  the  ensiform 
cartilage  marks  it  anteriorly.  A  graduated  riband  passed  from 
one  of  these  points  to  the  other,  across  each  side  of  the  thorax,  to 
the  level  of  the  nipple  in  the  male,  and  just  beneath  the  mamma  in 
the  female,  enables  us  to  ascertain  accurately  the  comparative  size 
of  the  two  sides  of  the  chest,  in  the  alternate  movements  of  in- 
spiration and  expiration.  Tn  aid  of  this  process,  which  should  be 
repeated  at  suitable  intervals,  the  physician  should  follow  out  the 
changes  induced  by  certain  diseases  in  the  volume  of  the  chest, 
particularly  by  pleurisy  with  eifusion. 

This  kind  of  mensuration,  however,  is  not  always  sufficient  for 
the  appreciation  of  alterations  in  the  volume,  and,  particularly,  the 
capacity  of  the  thorax.  In  some  cases,  indeed,  where  circular 
mensuration  detects  no  difference  in  the  extent  of  surface,  simple 
inspection  will  show  considerable  antero-posterior  depression  of  one 
side,  and  by  means  of  the  graduated  callipers,  and  particularly 
the  instrument  which  we  have  constructed  for  this  purpose,  f  a 
difference  of  from  an  inch  to  fifteen  lines  in  the  antero-posterior 
diameter  of  the  two  sides  may  be  detected,  and,  what  is  of  more 

*  This  process  consists  in  letting  fall,  from  the  upper  part  of  the  body  to  the 
pubis,  a  vertical  line  represented  by  a  cord  reaching  from  the  superior  notch  of  the 
sternum,  to  the  symphysis  pubis,  and  crossing  another  cord  extending  from  one 
anterior  superior  spinous  process  of  the  ilium  to  the  other.  Before  measuring 
the  limbs,  we  should  so  place  the  pelvis,  as  that  the  cords  shall  cross  at  right 
angles. 

f  This  instrument,  which  is  very  similar  to  that  used  by  shoemakers  for  meas- 
uring the  foot,  differs  from  it  in  having  upon  each  of  its  branches,  a  movable 
plate  ten  or  twelve  lines  in  breadth,  which,  resting  with  a  broad  surface  upon  the 
chest,  cannot,  like  the  branch  of  the  instrument,  be  alternately  placed  upon  an 
intercostal  space  and  a  prominent  rib,  which  condition  would  alter  the  results  of 
mensuration  and  might  lead  to  erroneous  conclusions. 


DIAGNOSIS.  285 

importance,  it  reveals  a  far  greater  change  in  the  capacity  of  the 
thorax,  than  that  occurring  in  cases  where  the  extent  of  surface, 
only,  is  diminished.  These  two  modes  of  exploration  have  ena- 
bled us  to  ascertain  two  facts,  of  considerable  interest  in  the  his- 
tory of  pleuritic  effusions :  first,  that  the  chest,  although  much 
contracted  after  chronic  pleurisy,  may  regain,  in  the  course  of 
years,  its  original  dimensions ;  secondly,  that  in  those  cases  where 
one  side  becomes  contracted  by  reason  of  the  compression  and 
atrophy  of  the  lung  therein  contained,  the  other  side  is  enlarged, 
as  if  to  supply  the  loss  of  power  in  its  companion,  in  conformity 
with  the  known  laws  of  pathological  physiology.  We  shall  men- 
tion a  single  fact,  only,  in  support  of  each  of  these  observations. 

Dr.  D.,  member  of  the  Faculty  of  Paris,  in  the  course  of  a 
chronic  pleurisy  of  the  left  side,  had  dilatation  of  the  side  and 
subsequent  contraction,  as  is  observed  in  the  majority  of  patients  ; 
by  means  of  often  repeated  circular  and  an tero- posterior  mensura- 
tion, the  various  modifications  of  the  conformation  of  the  thorax 
were  followed  and  appreciated.  After  several  years,  it  was  desir- 
able to  examine  anew,  in  order  to  judge  of  the  changes  gradually 
wrought  by  time  in  the  respiratory  murmur,  which  had  remained 
feeble,  and  also  in  the  conformation  of  the  left  side,  which,  after 
seven  or  eight  months  of  disease,  was  still  much  contracted.  This 
last  examination,  made  three  or  four  years  after  the  apparent  cure  of 
the  disease,  convinced  us  that  the  respiratory  murmur  had  regained 
its  normal  type,  and  what  was  yet  more  surprising,  that  the  left 
side  had  not  only  re-attained  a  size  equal  to  that  of  the  right,  but 
that  it  had  become  larger,  both  in  regard  to  its  superficies,  circu- 
larly measured  by  a  riband,  and  in  its  antero-posterior  diameter, 
measured  by  the  instrument  above  mentioned.  It  is  possible  that 
this  side  may  have  been  originally  larger  than  the  right. 

The  second  fact  relates  to  a  phthisical  young  girl,  who  was 
brought  to  the  clinical  wards  of  La  Charite  with  all  the  signs  of 
pneumo-thorax  upon  the  left  side,  and  in  whom  suffocation  seemed 
imminent.  Liquid  effusion  succeeded  to  that  of  gaseous  nature, 
and  its  absorption  was  very  gradual;  mensuration,  at  intervals  of 
eight  or  ten  days,  established  that  the  right  side  was  progressively 
dilated,  in  proportion  to  the  contraction  of  the  left,  although  the 
contraction  of  the  latter  must  have  opposed  the  enlargement  of  the 
former.  This  patient  survived  the  attack  of  pneumo-thorax,  and 
died  two  years  after,  from  the  gradual  progress  of  phthisis. 

Mensuration  of  the  abdomen  is  performed  with  a  graduated 
riband,  or  with  a  plain  one,  upon  which  the  result  of  each  meas- 
urement is  marked  with  ink.  This  exploration  is  particularly 
useful  in  abdominal  dropsy,  where  it  enables  us  to  appreciate  even 
the  slightest  modifications  in  the  volume  of  the  abdomen,  and  to 
deduce  from  thence  our  inferences  as  to  the  effect  of  the  treatment 
employed.  It  is  important,  however,  to  remember  that  the  volume 
of  the  abdomen  depends  both  upon  the  quantity  of  liquid  con- 
tained in  the  peritoneum  or  in  a  cyst,  and  upon  that  of  gases  and 
other  matters  confined  in  the  intestines.  The  alterations  which 


286  DIAGNOSIS. 

supervene  in  the  volume  of  the  abdomen,  do  not,  then,  give  us  the 
exact  measure  of  the  existing  modifications  in  the  quantity  of 
liquid  contained  in  the  abdomen :  percussion  must  concur  with 
mensuration  in  forming  the  opinion  of  the  physician  in  such  cases. 

Mensuration  is  still  farther  applicable  to  certain  tumors,  which 
are  sufficiently  superficial  to  allow  of  being  included  between  the 
branches  of  the  callipers  ;  although  little  employed,  there  are  cer- 
tain cases  where  it  may  be  useful ;  a  greater  degree  of  precision  in 
the  appreciation  of  the  changes  which  supervene  in  the  volume  of 
these  tumors,  furnishes  prognostic  and  therapeutical  indications 
which  should  not  be  neglected. 

Finally,  mensuration  becomes  a  valuable  means  in  the  appreci- 
ation of  the  pelvic  diameters,  especially  the  antero-posterior,  whose 
extent  it  is  very  important  accurately  to  ascertain,  with  reference 
to  parturition,  particularly  in  deformed  females.  Several  instru- 
ments invented  for  this  purpose  and  called  pelvimeters,*  have 
been  abandoned;  the  index  finger  is  to  be  preferred,  introduced  to 
a  sufficient  depth  into  the  vagina,  to  reach  with  its  extremity  the 
sacro-vertebral  angle,  while  its  base  rests  beneath  the  symphysis 
pubis ;  we  can  thus  estimate  this  diameter  within  one  or  two  lines. 

6.  Percussion.  Percussion  is  that  mode  of  exploration  whose 
special  purpose  is  to  ascertain  the  degree  of  resonance  presented 
by  various  parts  of  the  body.  It  is  by  a  species  of  percussion, 
likewise,  that  we  obtain  that  internal  impulse,  caused  by  a  sudden 
shock  communicated  to  a  liquid  confined  in  a  natural  or  accidental 
cavity  {fluctuation),  or  to  a  mass  of  hydatids  enclosed  in  a  cyst 
(hydatic  fremitus) ;  but  it  is  the  first  kind  of  percussion  only, 
which  will  be  here  considered. 

From  the  earliest  times  of  medicine,  percussion  seems  to  have 
been  employed  in  examinations  of  the  abdomen :  the  term  tympa- 
nitis, applied  by  the  Greek  physicians  to  considerable  gaseous 
distension  of  the  abdomen,  puts  it  beyond  a  doubt  that  they  had 
noticed,  by  means  of  percussion,  the  increase  of  resonance  in  this 
region.  The  utility  of  percussion,  however,  was  then  but  limited  : 
it  barely  sufficed  to  distinguish  between  dropsy  and  tympanitis. 
For  this  reason,  Avenbrugger  has  very  generally  and  justly  been 
considered  the  inventor  of  this  mode  of  exploration,  which  he  was 
the  first  to  apply  to  the  study  of  thoracic  diseases.  Since  the  pub- 
lication of  his  work,  in  1763,  and  especially  since  its  translation 
into  French  by  the  celebrated  Corvisart  (1808),  percussion  has 
become  one  of  the  most  employed  and  most  useful  of  diagnostic 
means :  every  day  has  added  to  its  importance,  either  because  it 

*  A  new  and  very  simple  pelvimeter  has  been  contrived,  consisting  of  two  pieces 
of  wood,  each  one  eighth  of  an  inch  square  and  eight  inches  long,  fastened 
together  in  the  centre  by  a  pivot,  so  as  to  form  a  cross  with  equal  legs.  The 
lower  extremity  of  one  of  these  legs  has  a  graduated  transverse  bar  attached, 
upon  which  the  other  leg  traverses.  Thus,  whatever  space  is  ascertained  by  the 
expansion  of  the  upper  legs  of  this  double  compress,  is  marked  by  the  separation 
of  the  lower.  All  that  is  required,  therefore,  is  to  introduce  the  upper  end, 
closed  with  the  finger,  and  to  open  it  when  in  the  pelvic  cavity.  —  (Medical 
Gazette,  Oct.  30,  1846).  — TRANS. 


DIAGNOSIS.  287 

has  been  more  carefully  studied  and  more  extensively  applied, 
or  because  the  discovery  of  auscultation  has  given  more  precision 
to  the  value  of  the  signs  furnished  by  percussion.  Finally,  by  the 
recent  labors  of  many  physicians,  and  particularly  of  M.  Piorry, 
percussion,  applied  to  the  observation  of  abdominal  disease,  has 
furnished  a  new  series  of  very  useful  diagnostic  signs.  (See 
page  151). 

In  order  thoroughly  to  appreciate  the  changes  wrought  by  dis- 
ease in  the  resonance  of  the  thorax,  the  physician  should  be  aware 
that  there  is  great  variation  in  regard  to  the  degree  of  resonance 
in  different  individuals,  and  that,  in  the  same  individual,  percus- 
sion furnishes  different  results,  according  to  the  parts  of  the  chest 
upon  which  it  is  practised.  Broad  chests,  clothed  with  voluminous 
muscles,  give,  most  generally,  an  obscure  sound  on  percussion, 
whatever  portion  may  be  examined.  In  very  thin  persons,  on 
the  contrary,  the  chest  resounds  clearly,  and  is  almost  tympanitic 
throughout.  In  all  cases  the  resonance  of  the  thorax  varies  ac- 
cording to  the  regions :  it  is  more  clear  beneath  the  clavicles,  in 
the  axillary  regions  and  in  the  lateral  portions ;  less  so  over  the 
scapulae  and  in  the  prgecordial  region  ;  the  latter  returns  an  obscure 
sound,  over  a  surface  of  from  one  and  a  half  to  two  square  inches, 
which  indicates  the  space  where  the  heart  remains  uncovered  by 
the  lungs ;  but  in  some  persons,  the  heart,  deeply  situated  in  the 
mediastinum,  has  its  anterior  surface  entirely  covered  by  the  lung, 
and  percussion,  practised  upon  the  cartilages  of  the  fifth  and  sixth 
ribs  and  the  lower  part  of  the  sternum,  gives  an  entirely  clear 
sound.  Below  the  heart,  the  thoracic  resonance  usually  becomes 
clearer  than  anywhere  else,  which  is  owing  to  the  presence  of  the 
stomach  and  its  gaseous  contents ;  on  the  right  side,  in  a  corres- 
ponding point,  the  sound  is  dull,  which  is  referable  to  the  liver. 
It  has  been  said  that  the  resonance  of  the  right  side  was  of  deeper 
tone  by  reason  of  the  greater  volume  of  the  lung ;  but  we  do  not 
consider  this  difference  sufficiently  established. 

Percussion  has  long  been  practised,  directly,  with  the  palm  of 
the  hand,  or  with  the  extremities  of  the  fingers.  This  mode  of 
percussion  has  the  disadvantage  of  causing  some  pain,  particularly 
in  the  mammary  and  abdominal  regions,  and  it  has  become  the 
practice  to  interpose  some  substance  between  the  hand  used  in 
percussion  and  the  part  percussed,  thus  diminishing  the  pain, 
while  the  degree  of  resonance  is  the  same  or  even  increased.  The 
latter  kind  of  percussion  is  called  mediate,  the  former  immediate. 
Many  instruments  have  been  devised  for  mediate  percussion.  An 
ivory  plate  with  projections,  so  that  it  may  be  firmly  held  (plezi- 
meter),  a  piece  of  silver,  or  of  caoutchouc,  have  all  been  proposed; 
but  we  prefer  the  index  finger  of  the  hand  not  used  in  percussion, 
(and  this  is  usually  the  left,)  because  it  can  be  better  applied  to  the 
chest,  and  causes  less  noise  than  either  ivory  or  metal,  and  also, 
because,  as  a  general  rule,  the  physician  should  not  have  recourse 
to  instrumental  aid,  except  in  cases  where  the  hand  is  insufficient. 
It  has  been  suggested  that  the  finger  which  serves  as  an  interme- 


288  DIAGNOSIS. 

diate  body,  be  placed  in  supination,  in  order  to  percuss  upon  the 
softer  palmar  portion,  which  is  less  sonorous  than  the  dorsal  por- 
tion :  we  regard  this  modification  as  of  little  consequence,  and 
employ  the  ringer  either  in  supination  or  pronation,  according  to 
the  patient's  position,  without  remarking  any  appreciable  differ- 
ence in  the  results  obtained. 

Whatever  mode  of  percussion  be  preferred,  certain  rules  should 
be  observed  in  its  practice. 

It  is  a  precept  of  general  application  in  all  modes  of  exploration, 
to  commence  by  an  examination  of  parts  somewhat  remote  from 
the  supposed  seat  of  disease ;  this  rule  is  equally  applicable  to 
pressure,  palpation,  percussion  arid  auscultation  :  a  previous  exam- 
ination of  healthy  parts  admits  of  more  accurate  appreciation  of 
the  alterations,  sometimes  but  slight,  which  take  place  in  diseased 
parts.  There  are,  however,  some  exceptions,  and  if  the  patient 
submitted  to  percussion  or  auscultation  of  the  chest,  be  so  feeble  that 
he  can  with  difficulty  assume  a  sitting  posture,  even  for  a  few 
seconds,  it  is  preferable  to  examine  the  affected  side  first,  lest  syn- 
cope might  prevent  a  more  extended  examination. 

When  either  percussion  or  auscultation  are  practised,  the  patient 
should  be  in  a  quiet  room,  and  those -present  should  remain  mo- 
tionless and  silent. 

The  parts  subjected  to  percussion  should  be  bare,  or  only  very 
thinly  clothed.  The  patient  should  be  in  a  sitting  posture  during 
percussion  of  the  thorax  ;  the  dorsal  decubitus  is  suitable  in  percus- 
sion of  the  abdomen,  and  is  admissible,  also,  for  the  front  chest. 
The  arms  should  be  maintained  in  similar  positions,  hanging  by 
the  sides  of  the  body,  when  we  percuss  in  front  or  behind ;  raised,  and 
the  hands  clasped  upon  the  head,  when  the  lateral  regions  are  per- 
cussed. The  physician  may  stand  indifferently  on  the  right  or  left 
of  the  patient  for  percussion  of  the  abdomen ;  for  that  of  the  thorax, 
his  position  should  be  such  as  will  enable  the  ringers  of  the  most 
practised  hand,  which  is  usually  the  right,  to  strike  at  right  angles 
and  with  uniform  force  upon  corresponding  points  of  the  chest,  on 
each  side,  either  anteriorly  or  posteriorly ;  this  is  one  reason  for 
desiring  persons  who  are  not  ill  enough  to  be  confined  to  bed,  to 
sit  on  a  chair  when  examined.  If  the  results  are  at  all  doubt- 
ful, we  should  percuss  comparatively,  standing  alternately  at  the 
right  and  left  of  the  patient,  and  employing  both  mediate  and  im- 
mediate percussion. 

It  is  generally  best,  in  children  and  thin  persons,  to  employ  medi- 
ate percussion,  with  a  single  finger :  the  medius  is  preferable,  which, 
by  its  greater  length,  naturally  extends  beyond  the  others.  If  the 
thoracic  integuments  are  of  considerable  thickness,  and  especially 
if  there  be  much  adipose  tissue,  a  greater  degree  of  force  will  gen- 
erally be  necessary,  and  two  fingers,  as  the  medius  and  index 
united,  should  be  employed,  and  sometimes,  even  all  the  fingers  joined 
together  and  forming  a  line.  Percussion  should  be  gentle  at  first, 
being  thus  less  painful  and  disagreeable  to  the  patient,  and  also 
because,  in  this  way,  the  sound  caused  by  the  percussing  finger 


DIAGNOSIS.  289 

is  nearly  null,  and  the  internal  resonance  more  easily  appre- 
ciated. The  force  with  which  we  percuss,  may  gradually  be 
augmented,  until  we  attain  that  degree  which  gives  the  most 
marked  results. 

Should  nothing  indicate  existing  lesions  within  the  thorax,  we 
limit  our  percussion  of  its  several  regions  to  three  or  four  points ;  if 
we  have  any  reason  to  fear  concealed  lesion,  we  should  percuss 
much  more  frequently,  and  not  renounce  the  idea  of  discovering 
some  disorder,  until  we  have  examined,  not  only  by  percussion,  but 
by  auscultation,  nearly  every  point  of  the  thoracic  surface. 

Abdominal  percussion  is  generally  practised  by  tapping  with 
the  medius  of  the  right  hand  upon  the  index  finger  of  the  left, 
which  is  made  to  glide  successively  from  above  downwards  over 
the  abdominal  parietes,  from  the  ensiform  cartilage  to  the  pubis. 
and  from  the  margin  of  the  ribs,  on  each  side,  to  the  ossa  ilia. 
The  resonance  of  the  abdomen,  like  that  of  the  chest,  varies,  in 
health,  according  to  the  thickness  of  the  integuments  and  the  flesh 
of  the  patients,  and  also  according  to  the  amount  of  gas  contained 
in  the  alimentary  canal,  which  may  vary  very  much  without  consti- 
tuting a  morbid  condition.  The  resonance  of  each  abdominal 
region  is  generally  proportionate  to  the  diameter  of  the  organs 
containing  the  gaseous  fluid :  in  the  normal  state,  the  stomach 
gives  the  clearest  sound  on  percussion,  and  the  large,  are  more  re- 
sonant than  the  small,  intestines. 

Abdominal  percussion,  in  disease,  conjointly  with  palpation 
and  pressure,  furnishes  a  great  number  of  important  signs.  In 
cases  of  general  distention  of  the  abdomen,  it  assists  us  in  ascer- 
taining whether  the  swelling  be  owing  to  an  accumulation  of  gas 
in  the  intestinal  canal,  to  liquid  effusion,  or  to  a  large,  solid  tumor 
entirely  filling  the  cavity.  In  the  first  case,  there  is  increased,  in 
the  two  others,  diminished,  resonance  :  in  one  of  the  latter  cases, 
fluctuation  reveals  liquid  effusion ;  in  the  other,  the  absence  of 
fluctuation  and  the  greater  resistance  to  pressure  declare  the  exist- 
ence of  a  solid  abdominal  tumor. 

In  cases  where  the  abdomen  presents  only  a  partial  tumefaction, 
percussion  upon  such  a  point,  when  a  clear  sound  is  returned,  indi- 
cates that  the  swelling  is  owing  to  gaseous  distention  of  a  portion 
of  the  intestinal  tube :  when  the  sound  is  flat,  the  presence  of  a 
solid  tumor  or  liquid  effusion  may  be  suspected  as  the  cause,  and 
in  certain  cases  where  there  is  a  medium  and  variable  resonance, 
a  fold  of  intestine  may  be  contained  in  the  tumor,  without  consti- 
tuting it  entirely.  Percussion,  in  conjunction  with  other  modes  of 
exploration,  assists  the  diagnosis  of  peritoneal  effusions,  of  tumors 
formed  by  the  uterus  and  ovaries  in  females,  by  the  bladder, 
spleen  and  liver  in  both  sexes,  and  reveals  the  alterations  effected 
by  time  and  remedies  in  the  course  of  these  diseases. 

Percussion,  while  it  allows  the  ear  to  distinguish  important  mod- 
ifications in  the  degree  of  resonance  of  diseased  parts,  imparts, 
also,  a  peculiar  sensation  to  the  finger,  which  may  be  valuable  in 
certain  cases.  Thus,  according  to  the  observations  of  M.  Piorry. 
25 


290  DIAGNOSIS. 

when  a  multilocular  ovarian  cyst  exists  in  the  abdomen,  whose 
compartments  contain  various  substances,  each  of  them  may  pre- 
sent a  different  degree  of  resistance  to  the  ringer,  and  this  phenom- 
enon concurs  with  pressure  and  palpation  in  the  determination  of 
the  seat  and  nature  of  the  tumor. 

7.  Auscultation. — Auscultation  is  that  mode  of  exploration  whose 
purpose  is  to  ascertain,  by  the  mediate  or  immediate  application  of 
the  ear  to  different  parts  of  the  healthy  or  diseased  body,  the 
various  sounds  which  may  be  produced,  and  to  appreciate  their 
semeiological  value. 

Auscultation  was  at  first  applied  by  its  inventor  to  the  study  of 
thoracic  affections  only,  and  we  have  previously  seen  (pp.  138, 166), 
what  a  number  of  important  signs  it  has  furnished  in  the  diag- 
nosis of  diseases  of  the  lungs,  heart,  and  their  respective  envelopes. 
But  Laennec  himself  was  aware  that  it  might  be  extended  to 
other  affections,  especially  to  certain  diseases  of  the  middle  ear, 
the  Eustachian  tube  and  the  mastoid  cells.  Subsequently,  a  number 
of  English  physicians  declared  its  utility  in  certain  cases  of  peri- 
tonitis with  formation  of  false  membranes.  MM.  Mayor  of  Ge- 
neva, Kergaradec,  and  afterwards  M.  Paul  Dubois  and  the  younger 
Noegele,  have  published  interesting  researches  upon  the  application 
of  auscultation  to  the  study  of  pregjnancy,  and  of  certain  condi- 
tions of  the  foetus  during  intra-uterine  life.  Finally,  some  sur- 
geons have  declared,  that  in  those  deep-seated  fractures  where 
crepitation  was  doubtful,  and  in  cases  of  urinary  calculi  where 
the  shock  of  the  sound  against  the  foreign  body  communicated 
only  an  obscure  and  doubtful  sensation,  they  could,  by  means  of 
auscultation,  distinctly  hear  the  collision  of  the  bony  fragments  and 
the  light  touch  (frolemenf)  of  the  catheter  against  the  surface  of 
the  calculus.  * 

Auscultation  may  be  practised  in  two  ways :  either  by  the  in- 
tervention of  the  acoustic  instrument  known  as  the  stethoscope 
(mediate  auscultation)  ;  or  by  the  direct  application  of  the  unassist- 
ed ear  to  the  parts  we  would  examine  (immediate  auscultation). 

Mediate  auscultation  was  the  only  method  advised  and  practised 
by  Laennec,  who  found  inconveniences  in  immediate  auscultation 

*  The  application  of  auscultation  to  the  diagnosis  of  cerebral  disease,  was  first 
introduced  to  the  profession  in  1834,  by  Dr.  Fisher,  of  Boston.  Subsequent  and 
more  extended  researches  led  him  to  announce  the  existence  of  an  encephalic 
bellows  murmur  in  many  cases  of  apoplexy  and  fracture  of  the  skull,  in  addition 
to  the  diseases  wherein  it  was  first  declared  to  be  evident,  viz.,  acute  and  chronic 
meningitis,  encephalitis,  during  the  accidents  of  dentition  and  in  pertussis.  The 
conclusions  drawn  by  Dr.  Fisher  from  his  researches  are  the  following  :  1.  The 
encephalic  bellows  murmur  does  not  exist  in  the  normal  state  of  the  encephalon. 
2.  It  may  be  easily  distinguished  from  the  other  sounds  heard  while  ausculting  the 
head,  as  the  sound  produced  by  the  passage  of  air  through  the  nares,  by  degluti- 
tion, locution,  and  the  cardiac  pulsations.  3.  Its  seat  is  the  arterial  trunks  at  the 
base  of  the  skull,  when  they  are  compressed  by  the  brain  ;  as  occurs  in  effusion, 
or  in  inflammatory  increase  of  volume  of  the  organ.  The  calibre  of  the  arteries 
being  diminished,  the  circulation  is  impeded,  and  this,  in  addition  to  the  resulting 
increase  of  friction,  is  the  source  of  the  bellows  murmur.  (See  American  Jour- 
nal of  the  Mtdical  Sciences.  August,  1838.)  — TRANS. 


DIAGNOSIS.  291 

which  seem  to  us  fictitious.*  In  the  last  edition  of  this  work,  we 
asserted,  that  in  our  own  experience,  immediate  auscultation  had 
presented  the  same  exactitude,  in  its  revelations  of  the  various 
auscultatory  phenomena,  as  that  by  means  of  the  stethoscope,  even 
when  employed  by  the  most  skilful.  Fifteen  years  of  observation 
have  confirmed  this  opinion  more  and  more,  and  it  is  entirely 
proved,  that  all  the  modifications  of  the  respiratory  murmur,  and 
all  the  rales  and  abnormal  sounds  of  which  the  lungs,  heart  and 
their  enveloping  membranes  may  be  the  seat,  are  as  appreciable  by 
the  unassisted  ear,  as  by  the  aid  of  the  stethoscope.  A  certain  de- 
gree of  practice  is  requisite  in  both  these  methods  of  exploration  ; 
but  skill  is  far  more  easily  acquired  in  immediate  than  mediate 
auscultation.  One  who  accustoms  himself  to  the  stethoscope,  hears 
with  more  difficulty  when  he  uses  the  unaided  ear ;  another,  (and 
this  is  our  experience)  more  familiar  with  immediate  auscultation, 
appreciates  far  better,  by  its  means,  the  phenomena  arising  from 
the  respiration,  voice,  and  movements  of  the  heart.  But,  supposing 
these  two  methods  to  be  the  same,  should  we  not  prefer  the  most 
simple  1 

Immediate  auscultation  presents  still  other  advantages :  1.  It 
requires  less  time,  which,  indeed,  is  of  little  importance  in  ordinary 
cases,  but  is  not  to  be  disregarded  in  those  where  the  debility  of 
the  patient  barely  allows  him  to  retain,  even  for  a  few  minutes,  the 
sitting  posture,  a  circumstance  of  frequent  occurrence.  2.  The  atten- 
tion of  the  physician  is  not  divided  between  maintaining  the  stetho- 
scope in  exact  application  to  the  parts  he  is  examining,  and  the 
appreciation  of  the  phenomena  which  he  studies  ;  it  is  not  impossi- 
ble, especially  in  the  case  of  those  who  have  not  acquired  great  skill 
in  the  use  of  the  stethoscope,  that  this  instrument,  being  improperly 
applied,  may  lead  the  observer  into  error  in  regard  to  the  phenom- 
ena which  he  is  desirous  of  studying,  while  immediate  ausculta- 
tion would  present  no  such  difficulties. 

*  Immediate  auscultation  is  equally  inconvenient  for  the  physician  and  the  pa- 
tient ;  disgust,  alone,  renders  it  impracticable  in  hospitals  ;  it  is  hardly  to  be 
thought  of  with  the  majority  of  females,  and  in  some,  the  size  of  the  mammae  is 
a  physical  obstacle  to  its  employment  ;  these  are  Laennec's  objections 

To  this  we  reply  :  1.  Immediate  auscultation  is  less  inconvenient  for  the  phy- 
sician than  mediate,  by  reason  of  the  firm  support  which  the  patient's  chest  affords 
the  head  ;  it  is  less  painful  for  the  patient,  for  the  pressure  of  the  ear  is  softer 
than  that  of  a  wooden  instrument ;  2.  Disgust  does  not  render  any  mode  of  ex- 
ploration impracticable;  it  is  also  completely  conquered  by  habit.  3.  Immediate 
auscultation  may  be  practised  with  such  propriety  that  no  reasonable  female  would 
object  to  it.  4.  Considerable  volume  of  the  mammae  is  quite  as  great  a  hindrance 
to  the  employment  of  the  cylinder,  as  to  that  of  the  ear.  5.  Lastly,  to  a  final 
objection  offered  by  Laennec,  viz.  "  that  all  the  parts  of  the  observer's  head, 
which  touch  the  thorax,  becoming  so  many  conductors  of  sound,  might  cause  the 
respiratory  murmur  to  be  heard  in  cases  where  it  did  not  exist  in  the  part  situated 
directly  beneath  the  ear,  which  might  occasion  serious  error,"  we  reply,  that  in 
no  case  have  we  seen  this  supposition  realized,  and  that  the  most  circumscribed 
lesions  of  the  lungs  have  seemed  to  us  as  easily  distinguished  by  the  unaided  ear, 
as  by  means  of  the  stethoscope.  In  conclusion,  we  add,  as  confirmatory  of  our 
opinion,  that,  at  present,  the  great  majority  of  practitioners  only  use  the  stetho- 
scope in  those  cases  where  there  exists  an  obstacle  to  immediate  auscultation. 
(See  p.  292  ) 


292  DIAGNOSIS. 

There  are,  however,  some  cases  where  mediate  auscultation  is 
preferable.  In  the  examination  of  an  cedematous  chest,  the  pres- 
sure of  the  stethoscope  displaces  the  serosity  and  enables  us  better 
to  appreciate  the  phenomena  of  auscultation.  At  other  times,  the 
form  of  the  parts  prevents  the  accurate  application  of  the  ear,  and 
renders  immediate  auscultation  impracticable.  In  some  phthisical 
patients,  for  instance,  where  the  emaciation  is  excessive,  the  con- 
siderable prominence  of  the  clavicle  and  acromion  process  of  the 
scapula  does  not  admit  the  application  of  the  ear  to  the  thoracic 
parietes  in  the  hollow  circumscribed  by  these  bones.  The  same  is 
true  in  certain  cases  of  rachitis,  where,  by  reason  of  deformity  of 
the  thorax,  the  stethoscope  alone  can  be  employed ;  such  is  also 
the  case,  and  for  analogous  reasons,  in  auscultation  of  the  arteries  ; 
for  if  we  except  the  cceliac  axis  and  the  arch  of  the  aorta,  to 
which  the  ear  can,  if  necessary,  be  directly  applied,  we  must  use 
the  stethoscope  for  all  the  others,  either  with  or  without  its  sup- 
plementary portion,  or  plug  (enbout).  Too  strong  pressure  upon 
the  artery  with  this  instrument  should  be  avoided  ;  its  effect  would 
be  to  produce  a  bellows  murmur  in  the  vessel,  which  would 
simulate  a  morbid  sound. 

Mediate  or  immediate  auscultation  is  practised  as  follows : 

In  the  first  place  it  is  more  convenient  entirely  to  uncover  the 
part  about  to  be  examined  ;  the  interposition  of  linen  alone  is  not, 
usually,  any  obstacle  to  this  sort  of  exploration  ;  indeed,  we  some- 
times observe  that  certain  thick  articles  of  clothing,  and  those 
doubled,  do  not  always  prevent  the  perception  of  auscultatory 
phenomena.  We  have  often  appreciated  these  phenomena  with 
great  accuracy  through  the  thick  garments  worn  in  the  cold  season, 
and  also,  through  linseed  cataplasms  entirely  enveloping  the  tho- 
rax in  children.  On  other  occasions,  the  contrary  is  observed, 
and  very  thin  clothing,  as  the  corsets  in  females,  or  the  starched 
shirt-bosom  in  males,  almost  wholly  prevents  the  perception  of 
phenomena  afforded  by  auscultation.  As  a  general  rule,  when 
nothing  opposes,  it  is  better  to  auscult  the  bare  surface. 

It  is  equally  necessary,  in  order  to  the  exact  perception  of  aus- 
cultatory phenomena,  that  the  muscles,  interposed  between  the  part 
examined  and  the  ear  of  the  observer,  be  entirely  relaxed  ;  their 
contraction  might  have  the  double  disadvantage  of  altering  the 
transmission  of  the  sounds  we  wish  to  study,  and  of  mingling  with 
them  other  sounds  arising  from  the  muscular  contraction  itself. 

In  mediate  auscultation,  the  stethoscope  should  be  held  like  a 
pen,  the  hand  being  placed  very  near  the  part  to  be  examined,  in 
order  to  be  sure  that  the  instrument  is  accurately  applied.  If  the 
patient  be  in  bed,  he  should  lie  upon  the  back  or  assume  a  sitting 
posture,  and  the  anterior  parts  of  the  chest  should  be  examined  in 
this  position,  the  auscultator  standing  alternately  upon  each  side 
of  the  bed  ;  in  the  examination  of  the  lateral  portions  and  axillary 
regions,  the  patient  should  be  inclined  to  the  opposite  side  ;  in  that 
of  the  back,  he  should  sit  up  in  bed,  the  body  slightly  bent  for- 
ward, the  arms  folded,  and  the  back  turned  toward  the  examiner. 


DIAGNOSIS.  293 

If  the  patient  be  sitting  up,  it  is  better  to  rest  upon  one  knee  than 
to  stoop,  in  the  examination  of  the  anterior  and  lateral  parts  of  the 
chest. 

Tn  immediate  auscultation,  the  patient  should  be  sitting,  either 
in  bed,  or  upon  a  chair  ;  the  physician,  standing  beside  him,  applies 
the  same  ear  successively  over  the  whole  anterior  thoracic  region, 
to  the  right  and  left,  at  corresponding  altitudes ;  the  right  ear 
should  be  employed  if  he  stand  on  the  patient's  left  hand,  the  left, 
if  on  his  right,  so  that  the  slightest  difference  presented  by  the  aus- 
cultatory  phenomena  in  corresponding  points  of  the  lungs  or  pleu- 
rae may  not  escape  observation.  The  patient's  arm  being  next 
held  in  an  elevated  position,  the  physician  applies  his  ear  to  the 
axillary  space  of  the  same  side  and  to  different  parts  of  the  lateral 
thoracic  region ;  he  passses  to  the  other  side  to  examine  the  dor- 
sal region,  the  opposite  axilla  and  corresponding  side  of  the  chest. 

Acuteness  of  the  sense  of  hearing  is  an  important  condition  in 
the  practice  of  auscultation,  and  the  inequality  of  this  sense,  in  the 
two  ears,  may  be  very  troublesome  to  the  auscultator,  especially 
when  the  phenomena  are  indistinct.  On  this  account,  when  both 
ears  are  not  equally  sensible  of  sound,  (and  this  is  perhaps  the 
most  common  case,)  the  physician  should  employ  exclusively  the 
most  acute  in  auscultation,  and  for  this  purpose  he  should  stand 
successively  on  the  right  and  left  of  the  patient,  so  that  he  may 
examine  with  the  same  ear  the  anterior  and  posterior  thoracic  re- 
gions. 

Whatever  be  the  mode  of  auscultation  employed,  the  respiration, 
cough  and  voice  are  successively  examined,  in  all  the  points  to 
which  the  ear  or  the  stethoscope  is  applied.  We  generally  com- 
mence by  listening  to  the  natural  respiratory  murmur,  that  is,  the 
patient  respiring  in  his  usual  manner  and  with  no  more  than  ordi- 
nary muscular  force  and  rapidity.  We  thus  ascertain  the  strength 
or  feebleness  of  the  respiratory  sound,  whether  it  be  soft,  or  rude 
in  character,  and  the  rales  by  which  it  is  accompanied  in  the  alter- 
nate movements  of  inspiration  and  expiration,  whose  duration  also 
is  observed.  If  we  do  not  distinctly  perceive  the  respiratory 
murmur,  we  desire  the  patient  to  breathe  more  fully  or  rapidly^ 
as  if  sighing;  also,  to  cough,  for,  in  certain  cases,  it  is  only  during 
the  long  inspirations  which  precede,  or  follow  the  cough,  that  we 
distinguish  the  fine,  dry  crepitus,  or  the  bronchial  respiration  of 
pneumonia.  One  or  two  questions  should  be  asked  him,  that  we 
may  ascertain  whether  the  voice  have  a  ringing  character.  In 
auscultation  of  the  anterior  thoracic  region,  the  patient  should  be 
desired  to  turn  the  head  away  from  the  auscultator.  This  pre- 
caution always  has  the  advantage  of  avoiding  the  inhalation  of  his 
breath,  and  facilitates  auscultation  of  the  voice.  It  is  absolutely 
necessary  in  immediate  auscultation  of  the  anterior  and  superior 
thoracic  regions,  it  being  very  inconvenient  to  apply  the  head  to 
those  parts,  except  the  patient  turn  his  own  in  the  opposite  direc- 
tion. 

8.  Exploration  with  Sounds  and  Probes. —  Sounds  and  probes 
25* 


294  DIAGNOSIS. 

have  always  been  employed  in  tracing  the  course  of  fistulous 
ulcers,  and  the  lesions  of  parts  situated  beneath  these  fistulas,  par- 
ticularly the  bones  and  cartilages;  it  is  by  means  of  metallic 
sounds,  also,  introduced  into  the  bladder,  that  we  discover  the  pres- 
ence of  calculi,  a  shock  being  transmitted,  by  means  of  the  instru- 
ment, to  the  hand  which  directs  it.  For  the  purpose  of  ascertain- 
ing the  form,  degree,  and  exact  seat  of  strictures  in  the  urethra, 
soft  bougies  have  been  introduced,  capable  of  receiving  and  retain- 
ing the  form  of  the  parts  with  which  they  are  for  a  time  kept  in 
contact,  and  it  has  been  supposed  that  the  resulting  impressions 
represent  accurately  the  lesions  existing  in  the  urethra.  But  expe- 
rience has  shown  that  this  mode  of  exploration  does  not  merit  all 
the  confidence  which  some  surgeons  have  too  hastily  ascribed  to 
it.  Flexible  sounds  are  still  employed  in  certain  diseases  of  the 
rectum  and  oesophagus,  for  the  discovery  of  foreign  bodies  or  stric- 
tures not  within  reach  of  the  finger.  But  the  signs  which  may  be 
deduced  from  tfie  difficulty  experienced  in  passing  these  instru- 
ments, have  less  value  than  those  furnished  by  the  introduction  of 
the  finger. 

9.  Exploration  by  Specula. — Various  instruments  have  been 
imagined  for  the  examination  of  deep-seated  organs,  to  which  the 
name  speculum  *  has  been  given  :  their  purpose  is  to  enable  the 
physician,  bbth  to  discover,  by  the  eye,  the  many  alterations  which 
without  their  aid  would  be  inaccessible  to  vision,  and  also  to  ap- 
ply to  the  diseased  parts  the  different  remedies  required. 

Specula  generally  consist  of  hollow  cylinders,  with  or  without 
the  central  shaft  intended  to  render  their  introduction  more 
easy,  and  which  is  removed  after  the  instrument  itself  is  intro- 
duced. This  shaft  is  indispensable  when  the  speculum  is  used 
for  the  examination  of  a  passage  closed  by  a  sphincter,  as  the  rec- 
tum; it  has  hardly  any  advantage  in  the  contrary  case,  especially 
in  examinations  of  the  vagina  and  uterus.  The  form  of  specula 
has  been  almost  infinitely  varied,  but  these  numerous  varieties 
depend  upon  two  principal  conditions;  one  class  are  made  entire, 
and  represent  a  conic  cylinder,  others  consist  of  several  pieces, 
tvhich  glide  upon  one  another  so  that  the  instrument  may  be  as 
small  as  possible  when  introduced,  and  that  after  its  introduction 
it  may  be  so  far  expanded  as  is  compatible  with  the  construction 
of  the  parts  to  be  examined,  and  as  much  as  the  examination  de- 
mands. The  four-bladed  speculum  seems  to  us  far  preferable  to 
all  the  others  in  examinations  of  the  uterus,  and  even  of  the  rec- 
tum ;  it  has.  moreover,  this  advantage,  that  we  can,  if  necessary, 
detach  one  or  two  blades,  for  the  better  inspection  of  one  side  of 
the  passage  we  examine.  The  two-bladed  speculum  is  nearly  ex- 
clusively used  for  the  auditory  canal.  It  is  of  great  service  in  the 
diagnosis  of  various  affections  of  which  the  tympanum  is  the  seat. 
It  has  the  advantage  of  straightening  the  curves  of  the  meatus  au- 
ditorius  externus,  and  rendering  more  easy  and  complete  an 

*  Mirror. 


DIAGNOSIS.  295 

examination,  which  might,  it  is  true,  be  made  without  the  instru- 
ment. 

The  speculum  intended  for  exploration  of  the  rectum  (speculum 
ani),  is  but  rarely  employed ;  its  introduction  is  generally  painful, 
and  the  impossibility  of  giving  a  sufficiently  large  diameter  for 
the  requisite  admission  of  light  to  the  parts  exposed,  without  caus- 
ing too  severe  suffering  to  the  patient,  restricts  the  number  of  cases 
in  which  it  is  useful,  to  those  in  which  the  disease  is  near  the 
anus ;  the  vegetations,  fissures  or  perforations  so  often  occurring 
in  this  portion  of  the  intestine,  can  be  observed  by  means  of  this 
instrument. 

In  uterine  affections  the  speculum  is  far  more  frequently  used, 
and  its  application  is  much  more  advantageous.  The  diagnosis  of 
diseases  of  the  cervix  uteri  has  been  much  facilitated  by  its  em- 
ployment; lesions  of  this  part  can  thus  be  appreciated  by  the  eye, 
arid  their  progress  traced  as  readily  as  that  of  external  affections. 
Granular  nietritis,  a  very  frequent  and  unimportant  disease,  ranked 
by  some  surgeons  (quite  improperly,  as  we  think)  among  the 
most  dangerous  of  uterine  diseases,  under  the  term  ulcer  at  ions, 
remained  nearly  unknown  until  the  period  when  the  speculum 
was  employed.  By  means  of  this  instrument,  certain  small,  red 
agglomerated  elevations  have  been  discovered  around  the  margin 
of  the  uterine  orifice,  forming  by  their  union  a  circular  or  oval 
patch,  well  circumscribed,  resembling  the  raspberry  in  color  and 
inequality  of  surface,  and  very  easily  distinguished  by  these  two 
conditions  from  the  healthy  portion  of  the  os  tincae.  Since  the  dis- 
covery of  this  affection  by  the  speculum,  the  touch,  previously  un- 
able to  appreciate  it,  has  furnished  us  with  a  sign  by  which,  at 
present,  we  succeed  in  recognizing,  or  at  least,  are  led  to  suspect 
it.  If,  when  examining  the  surface  of  the  os  tincae  with  the  ex- 
tremity of  the  finger,  we  find,  within  and  around  the  uterine 
orifice,  a  soft  and  somewhat  uneven  surface,  imparting  a  sensa- 
tion comparable  to  that  occasioned  by  touching  the  fabric  known 
by  the  name  of  Utrecht  velvet,  while  the  eccentric  portion  of  the 
os  tincse  is  firm  and  smooth,  the  existence  of  this  granular  affec- 
tion can  hardly  be  doubted,  and  we  should  immediately  ha^e 
recourse  to  the  speculum  to  verify  the  diagnosis.  The  speculum 
enables  us,  moreover,  to  ascertain  the  nature  of  the  liquid,  fre- 
quently viscous  and  transparent,  which  escapes  from  the  uterine 
orifice;  we  can  also  perceive,  (especially  it'  the  instrument  be 
slowly  withdrawn  and  sufficiently  expanded,)  the  alterations  in 
the  color,  surface,  and  secretions  of  the  vaginal  mucous  membrane. 

The  introduction  of  the  speculum  into  the  rectum  and  vagina, 
requires  certain  precautions.  Previous  examination  of  the  parts 
should  be  made  with  the  finger,  and  in  those  cases  only  where 
this  first  examination  has  revealed,  or  led  us  to  suspect  certain 
lesions,  and  no  obstacle  to  the  introduction  of  the  speculum  exists, 
is  it  advisable  to  proceed  to  one  which  is  yet  more  repugnant  to 
the  patient.  The  cerate  carried  by  the  finger  into  the  rectum  or 
vagina,  renders  the  introduction  of  the  speculum  more  easy,  and 


296  DIAGNOSIS. 

this  instrument  is  guided  more  accurately  and  carefully  towards 
the  diseased  part  when  the  finger  has  already  ascertained  the  seat, 
and,  in  some  instances,  the  nature,  of  the  affection.  It  is  hardly 
necessary  to  add,  that  a  considerable  contraction  of  the  vagina  or 
rectum  would  be  an  obstacle,  and  sometimes  a  complete  one,  to 
this  sort  of  exploration.  In  the  examination  of  the  uterus,  the  po- 
sition of  the  cervix  being  ascertained  and  sometimes  rectified  by 
means  of  the  finger,  the  physician  is  more  confident  in  regard  to 
the  direction  which  should  be  given  to  the  speculum.  If  the  touch 
discover  cancerous  degeneration  of  the  vaginal  or  rectal  parietes, 
we  should  abstain  from  introducing  the  speculum,  or  should  use  it 
with  great  circumspection  ;  for  there  are  cases  in  which  the  dis- 
eased parts  are  so  softened  or  attenuated,  that  the  introduction  of 
the  instrument,  and  particularly  the  development  of  its  valves, 
might  cause  a  rupture  whose  consequences  would  be  exceedingly 
serious. 

In  all  cases,  even  when  the  touch  has  not  revealed  any  serious 
lesion  of  the  parts  into  which  the  speculum  is  introduced,  we  should 
proceed  to  this  examination  methodically  and  carefully.  The  ex- 
ternal surface  of  the  instrument,  and  above  all,  its  extremity,  as 
well  as  the  central  shaft,  if  thought  necessary,  must  be  covered 
with  a  thick  coating  of  cerate  or  some  other  unctuous  substance. 
In  examination  of  the  rectum,  the  patient  should  lie  upon  the  side : 
care  should  be  taken  in  the  introduction  of  the  speculum  that  it  be 
effected  slowly  and  at  a  moment  when  the  sphincter  is  relaxed. 

In  uterine  examinations,  the  dorsal  decubitus  is  preferable,  the 
thighs  should  be  flexed  and  separated,  and  the  feet  should  rest 
upon  a  support  some  inches  lower  than  the  pelvis.  In  introducing 
the  speculum,  we  should  press  moderately  against  the  perinatal 
surface  of  the  vagina,  until  it  passes  the  pubic  arch ;  the  trans- 
verse line  formed  by  the  contact  of  the  two  vaginal  parietes,  which 
are  seen  in  front  of  the  instrument,  indicates  the  direction  which 
should  be  given  to  it.  This  line,  receding  before  the  instrument, 
conducts  it  to  the  os  tincse,  which  is  easily  recognized  by  its  rounded 
form  and  the  absence  of  the  rugae  presented  by  the  vaginal  pa- 
rjptes.  The  blades  of  the  speculum  should  then  be  gradually  ex- 
panded, taking  care  that  they  do  not  touch  the  os  tincae,  whose 
surface  might  be  lacerated  by  them,  and  this  organ  comes  fully 
into  view  at  the  extremity  of  the  vagina.  The  mucus  which  fre- 
quently covers  it  may  then  be  removed  with  pledgets  of  lint, 
applied  by  means  of  long  forceps,  and  its  color,  form  and  volume, 
readily  ascertained.  If  the  day  be  dark,  a  candle  may  be  placed 
before  a  teaspoon,  whose  concave  surface  will  act  as  a  reflector. 

Exploration  of  far  more  deeply  seated  parts,  has  been  attempted 
by  means  of  very  complicated  specula :  among  these  are  the  in- 
strument proposed  by  Bambolzini,  for  the  examination  of  deep 
cavities,  particularly  the  stomach,  and  that  invented  by  a  mechan- 
ician affected  with  ulceratioii  of  the  larynx,  to  enable  his  physi- 
cian, M.  Trousseau,  to  inspect  the  cavity  of  this  organ;  that 
proposed  by  M.  Segalas  for  the  urethra  and  bladder,  to  ascertain 


DIAGNOSIS.  297 

the  state  of  the  mucous  membrane  and  the  actual  existence  of 
calculus,  is  of  the  same  description.  Hitherto,  however,  these 
ingenious  inventions  have  remained  nearly  inapplicable. 

10.  Examinations  with  the  Microscope  and  Magnifying  Glass. 
Although  the  unassisted  eye  suffices,  in  most  cases,  for  the  observa- 
tion of  pathological  phenomena  we  cannot  doubt  that  the  aid  of 
those  instruments,  intended  either  to  magnify  very  small  objects, 
or  to  render  visible,  bodies  wholly  imperceptible  to  ordinary  vision, 
possesses  in  all  cases  a  certain  degree  of  interest,  and  must,  in 
some  instances,  furnish  useful  results. 

We  have  previously  seen  that  the  microscope  was  necessary  for 
the  discovery  of  certain  substances  contained  in  urinary  deposits, 
and  for  the  determination  of  their  nature.  It  may  be  equally 
useful  in  appreciating  certain  alterations  of  the  milk  or  of  the 
blood  corpuscles,  and,  especially,  the  presence  of  pus  in  the  latter 
liquid,  when  the  precaution  has  been  taken  to  prevent  its  coagula- 
tion by  depriving  it  of  its  fibrine.  But  it  should  be  remembered  that 
the  microscope  requires  long  practice  ;  this  explains  the  often  con- 
tradictory results  obtained  by  different  observers.  For  this  reason 
we  should  not  admit  any  observations  as  exact,  unless  they  are 
verified  a  certain  number  of  times;  and  by  various  persons  accus- 
tomed to  these  researches. 

The  magnifying  glass  (loupe)  is  more  easily  and  generally 
employed  :  it  enlarges  objects  sufficiently  to  enable  us  to  recognise 
the  presence  of  the  acarus  scabiei,  and,  of  course,  the  head  of  the 
tape  worm.  With  this  instrument,  also,  certain  superficial  erosions 
of  the  cornea  may  be  perceived,  and  the  species  of  some  cutaneous 
affections,  about  to  declare  themselves,  be  determined  at  their 
commencement,  etc. 

11.  Employment  of   Chemical  Reagents  in  the  Diagnosis  of 
Disease. —  There  are  some  affections  whose  diagnosis  is  impossible 
without  the  aid  of  chemical  agents :  such  is  diabetes  mellitus ;  and, 
also,  that  disease  of  the  kidneys,  in  which  the  urine  becomes  albu- 
minous.    The  assistance  of  chemistry  is  necessary  in  these  cases, 
not  only  to  determine  the  nature  of  the  disease,  but  also  to  follow 
it  in  its  progress,  and  appreciate  the  changes  effected  in  its  inten^ 
sity  by  time  and  remedies,  and  finally,  to  verify,  in  some  cases, 
the  complete  disappearance  of  a  malady  too  often  rebellious  under 
every  kind  of  treatment. 

Among  the  diagnostic  aids  borrowed  by  medicine  from  chem- 
istry, there  are  some  easily  employed,  and  whose  application  should 
be  familiar  to  every  physician  :  such  are  tournesol  *  and  turmeric 
paper,  for  determining  the  acid  or  alkaline  quality  of  liquids,  and 
nitric  acid  for  detecting  the  presence  of  albumen  in  the  urine,  or 
for  precipitating  the  coloring  matter  held  in  suspension  by  the  bile. 
When,  on  the  contrary,  it  becomes  necessary  to  undertake  a  series 
of  experiments  which  require  much  time  and  great  experience,  it  is 
both  proper  and  indispensable  to  entrust  such  researches  to  persons 
who  have  paid  particular  attention  to  these  branches. 

*  Heliotropium  Europaeum.  —  TRANS. 


298  DIAGNOSIS. 

Having  stated  the  principal  means  of  exploration  which  the 
physician  should  thoroughly  understand  in  order  to  diagnose  dis- 
ease, we  shall  in  the  next  place  describe  the  proper  mode  of  exam- 
ining patients. 

$  III.  Proper  Manner  of  examining  and  interrogating  Patients, 
for  the  purpose  of  Diagnosis. — When  visiting  a  patient  for  the 
first  time,  the  physician  should  commence  by  a  rapid  general 
examination.  If  the  patient  be  up,  his  attitude  and  gait  are  the 
first  objects  of  attention  ;  if  he  be  in  bed  and  nothing  prevent,  it 
is  of  service  to  uncover  him  completely,  in  order  better  to  appreci- 
ate his  strength,  flesh,  stature,  and  the  various  phenomena  afforded 
by  external  appearance,  such  as  certain  eruptions,  mutilations  and 
deformities.  This  first  examination  is  almost  always  sufficient  for 
the  recognition  of  recent  or  chronic  diseases,  and,  in  some  cases, 
even  for  concluding  that  an  acute  has  supervened  upon  a  chronic 
affection.  If,  for  example,  we  visit  a  patient  at  mid-day  and  ob- 
serve that  redness  of  the  face,  increased  heat,  frequent  pulse  and 
prostration  which  belong  to  acute  disease,  the  existence  of  this 
complication  is,  at  any  rate,  very  probable. 

Successive  examination  of  the  various  regions  of  the  body  may 
furnish  very  important  signs,  not  only  in  external,  but  also  in  in- 
ternal affections.  In  external  diseases,  simple  inspection  of  the 
affected  part  is  often  sufficient  to  establish  the  diagnosis.  In 
certain  general  affections,  as  scorbutus,  syphilis,  etc.,  the  ecchy- 
moses,  pustules,  maculae  and  exostoses  inform  us,  at  a  glance,  of 
the  nature  of  the  disease.  Cicatrices,  also,  deserve  special  atten- 
tion, particularly  when  they  occupy  the  superior  cervical  and  the 
inguinal  regions.  The  former  are  almost  always  the  result  of 
scrofulous  tumors :  the  latter  of  a  syphilitic  bubo  which  has  sup- 
purated. The  existing  disease  may  have  some  connection  with 
one  or  other  of  these  affections,  and  it  is  so  much  the  more  impor- 
tant that  the  physician  be  aware  of  their  former  existence,  because 
many  patients  neglect  or  voluntarily  refrain  from  mentioning 
them.  * 

If  the  patient  have  lost  a  limb,  a  finger  or  one  of  the  phalanges, 
me  physician  should  never  neglect  to  inquire  the  cause  which 
rendered  the  loss  of  the  part  necessary.  If  it  were  white  swelling 
which  required  amputation,  this  circumstance  may  have  great 
weight  in  diagnosing  an  internal  affection :  if,  for  instance,  the 
individual  who  has  undergone  this  operation,  present  the  symp- 
toms of  chronic  pulmonary  catarrh  with  emaciation,  we  should 
fear  the  existence  of  tubercles  in  the  lungs ;  if  his  abdomen  be 

*  The  cicatrix  resulting  from  a  burn,  a  blister  or  an  ulcer  of  long  standing, 
deserves  also  the  physician's  attention,  less,  perhaps,  in  a  diagnostic  than  in  a 
therapeutic  point  of  view.  It  is  well  known  that  the  suppression  of  an  issue  and 
the  healing  of  a  chronic  ulcer  are  often  followed  by  the  development  of  some 
grave  affection,  which  does  not  yield  except  on  there-establishment,  natural  or 
artificial,  of  these  discharges ;  the  same  is  true  of  the  maculae  which  succeed 
certain  herpetic  eruptions. 


DIAGNOSIS.  299 

harder  and  more  voluminous  than  common,  if  the  stools  are  fre- 
quent and  liquid,  it  is  to  be  feared  that  the  mensenteric  glands  are 
the  seat  of  incurable  degeneration.  Deformity  of  a  limb  or  of  the 
nose,  etc.,  require  the  same  questions.  The  physician  should 
always  know  whether  these  deformities  are  congenital  or  acquired, 
and,  in  the  latter  case,  what  is  the  productive  cause. 

When  disease  of  very  different  character  from  those  ordinarily 
manifested  makes  its  appearance  in  an  individual  with  congenital 
malformation,  we  should  ascertain  if  this  disease  existed  from 
birth,  or  whether  it  appeared  a  long  time  afterwards.  In  the 
former  case,  we  may  reasonably  suppose  that  the  unusual  symp- 
toms complained  of  by  the  patient  are  owing  to  internal  deformity, 
because  observation  has  taught  us  that  any  deformity  rarely  exists 
alone  :  almost  always  there  are  several  coexistent,  and  very  often 
a  faulty  internal  organization  corresponds  to  that  manifested  ex- 
ternally. 

External  appearance,  moreover,  supplies  us  with  certain  other 
valuable  diagnostic  signs,  in  those  who  work  the  metals.  It  is 
not  very  uncommon  to  see  patients  brought  to  the  hospitals  with 
convulsions,  delirium  or  coma,  and  consequently  unable  to  give 
any  information  relative  to  the  causes  of  such  affections,  and  in 
whom  the  red  color  of  the  hair,  beard  and  eyebrows,  or  the  pres- 
ence of  a  white  powder  at  the  root  of  the  nails,  make  it  almost 
certain  that  the  illness  is  caused,  in  the  former,  by  minium  ;  in  the 
latter,  by  carbonate  of  lead. 

This  hasty  examination  of  the  exterior  of  the  body,*  as  we 
perceive,  furnishes  valuable  diagnostic  signs,  especially  when  the 
physician  wholly  uncovers  the  patient.  This  we  never  fail  to  do, 
after  the  example  of  Corvisart  and  Bayle,  in  the  male  wards  of 
the  hospitals ;  and  also  in  private  practice,  whenever  it  is  possible. 
Every  one  perceives,  in  part,  at  least,  the  advantages  resulting 
from  this  mode  of  examining  patients ;  but  in  order  thoroughly  to 
appreciate  them,  it  must  be  individually  practised  for  a  certain 
time.  We  have  ascertained  that  it  often  enables  us  to  dispense  with 
a  multitude  of  useless  questions,  and  leads,  in  many  cases,  to  a 
knowledge  of  circumstances,  which,  without  its  aid,  would  have 
remained  undiscovered. 

*  A  new  means  of  diagnosis  of  the  tuberculous  diathesis,  has  been  lately  an- 
nounced, derived  from  the  external  appearance  (habitude  exterieure).  "  When  a 
child  is  observed  with  dark  irides,  colorless  cheeks  and  darkish  hair  (the  eyes 
often  full  and  large,  the  eyelashes  very  long  and  close  together),  the  forehead  cov- 
ered with  close-lying  hair,  sometimes  almost  down  to  the  eyebrows,  its  arms  and 
back  from  the  hair  of  the  head  down  between  the  scapulae,  quite  hairy,  the  hairs 
often  being  very  thickly  placed  and  dark  in  color,  cachexia  often  being  coexistent ; 
in  nine  cases  out  often,  such  a  child  is  tuberculous;  either  having  tubercles 
already  deposited,  or  liable  to  have  them,  in  almost  every  organ  of  the  body,  the 
lungs  especially.  This  hairy  condition  in  a  cachectic  or  unhealthy  looking  child, 
is  a  sign,  generally  speaking,  of  a  constitution  miserable  in  the  extreme,  saturated 
with  scrofula."  — (Dr.  Wilshire.  Med.  Times,  April  10,  1847.)  Does  not  the 
confessedly  existing  cachexia,  detract  from  the  value  of  the  concomitant  alleged 
diagnostic  sign,  being  in  itself  sufficient  evidence  of  the  tuberculous  diathesis? 
Were  these  "  hairy  "  children  always  stuffed  with  tubercles,  when  not  cachectic  in 
external  appearance,  the  above  would  be  an  indubitable  diagnostic  sign.  —  TRA.NS. 


300  DIAGNOSIS. 

Simultaneously  with  this  rapid,  but  still  careful  external  exami- 
nation, the  physician  commences  his  questions.  Two  important 
points  here  present  themselves  :  the  mode  of  questioning,  and  the 
order  in  which  questions  should  be  asked. 

When  interrogating  a  patient,  the  physician  should  employ  those 
terms  only  which  are  easily  understood ;  he  should  assure  himself, 
if  doubtful,  that  he  has  been  well  comprehended,  by  repeating  a 
second  and  even  a  third  time,  if  necessary,  the  same  question  in 
different  terms  from  those  first  employed.  He  should  so  manage 
that  the  patient  shall  state  of  his  own  accord,  as  far  as  may  be, 
all  that  is  necessary  to  learn  from  him,  and,  for  this  purpose,  his 
questions  should  be  such  that  they  cannot  be  answered  by  simple 
affirmation  and  negation.  Without  this  precaution,  the  physician 
renders  the  patient  liable  to  state  his  case  far  otherwise  than  if 
he  had  told  it  without  restraint. 

It  is  equally  necessary  for  the  physician  to  pursue  a  regular 
course  in  questioning  his  patients ;  otherwise,  he  exposes  himself 
to  forget  important  questions  and  to  repeat  others,  at  any  rate, 
needlessly,  sometimes,  injuriously  to  the  patient,*  and  always  to  his 
own  disadvantage.  We  say  to  his  disadvantage ;  for  the  patient 
who  notices  this,  will  think  his  attention  distracted,  and  from  that 
moment  his  confidence  in  him  is  impaired.  The  number  of  ques- 
tions necessarily  varies  according  to  the  case.  Generally,  they 
should  neither  be  too  many  nor  too  few ;  it  is  nearly  as  important 
to  omit  those  which  can  be  of  no  service,  as  not  to  neglect  those 
that  are  necessary ;  the  physician  who  wishes  to  know  the  minutest 
details,  is  more  exposed,  than  another,  to  neglect  essential  points,  or 
to  forget  them  after  having  ascertained  them.  It  is  hardly  neces- 
sary to  add,  that  he  who  has  not  acquired  the  habit  of  seeing  and 
interrogating  patients  needs  to  ask  a  great  number  of  questions  in 
order  to  form  his  opinion,  while  the  experienced  practitioner  often 
attains  this  result,  by  the  aid  of  signs  furnished  by  the  external 
appearance,  and  from  limited  information  given  by  the  patient  or 
the  assistants.  So  much  the  more  important  is  it  for  the  physi- 
cian, on  account  of  his  reputation,  to  proceed  methodically  in  the 
examination  of  his  patients,  because  his  fellow-physicians  form 
their  opinion  of  him  from  such  grounds.  "  A  physician  who  listens 
to  the  interrogations  made  by  another  to  a  patient,  judges  imme- 
diately whether  he  is  well  informed  ;  and  if  so,  he  readily  sees  the 
reason  of  each  question,  why  he  passes  from  one  to  the  other  and 
the  order  in  which  they  are  asked.  The  most  thoroughly  informed 
physician,"  we  should  rather  say,  the  most  skilful,  "is  he  who 
asks  the  fewest  questions  in  diagnosing  disease."  f 

The  following  has  seemed  to  us  the  best  order  to  follow  in 
questioning  a  patient  seen  for  the  first  time. 

*  The  patient's  interest  sometimes  requires  that  the  number  of  questions  should 
be  very  restricted  :  in  diseases  where  silence  is  necessary,  and  particularly  in  in- 
flammations of  the  respiratory  and  vocal  organs,  as  in  haemoptysis,  many  ques- 
tions would  always  prove  injurious. 

f  Theses,  1808,  No.  138.  M.  Falvard- Mont-Luc. 


DIAGNOSIS.  301 

1.  We  commence  by  asking  his  age,  occupation,  place  of  resi- 
dence, customary  diet  and  usual   habits  of  life ;  whether   he  is 
habitually  in  good  health  or  otherwise,  and  what  illness  he  may 
have  had.     These  questions  are  not  always  useful  in  diagnosis, 
but  it  is  sufficient  that  they  may  be  so  in  certain  cases,  to  induce 
us  never  to  neglect  them. 

2.  We  next  ascertain  the  period  of  commencement  of  the  exist- 
ing disease ;  this  should  be  determined  with  the  greatest  possible 
precision,  especially  in  acute  diseases :  on  this  account  the  physi- 
cian should  rarely  content  himself  with  the  patient's  first  replies, 
particularly  in  hospital  practice.     Indeed,  the  lower  classes  disre- 
gard the  functional  disturbance  which  occurs  during  the  first  days 
of  the  disease,  and  do  not  consider  themselves  ill,  except  from  the 
moment  when  they  have  left  their  work,  or  abstained  from  food, 
or  from  the  day  when  they  experienced  severe  pain.     We  must, 
then,  if  we  would  be  exact,  review  all  the  functions  from  the  day 
when  the  slightest  disturbance  occurred,  to  the  moment  of  exam- 
ination. 

In  chronic  diseases,  as  we  have  elsewhere  seen,  the  transition 
from  health  to  sickness  is  almost  always  insensible,  and  it  is  often 
difficult  to  determine,  even  approximatively,  the  period  when  the 
disease  commences.  The  external  appearance  of  the  patient  is 
then  often  at  variance  with  his  replies ;  it  announces  a  disease 
already  of  long  standing,  while  he  complains  only  of  some  days 
or  weeks  of  indisposition.  It  is  generally  easy  to  form  a  cor- 
rect opinion,  by  asking  the  patient  himself,  or  those  who  reside 
with  him,  whether  previously  to  the  period  to  which  he  refers  the 
commencement  of  his  disease,  he  did  not  experience  some  indispo- 
sition, some  diminution  of  appetite,  strength  or  flesh. 

By  the  following  questions,  we  endeavor  to  ascertain  if  the  pro- 
gress of  the  disease  has  been  slow  or  rapid ;  if  there  have  been 
sudden  exasperations  or  gradual  increase;  if  the  symptoms  have 
been  the  same  from  the  invasion;  if  they  have  persisted  without 
interruption,  or  have  been  manifested  at  intervals ;  whether  some 
of  those  originally  observed  have  disappeared,  and  whether  others 
have  supervened.  When  the  patient  is  confined  to  his  bed.  we 
should  not  forget  to  inquire  since  when,  and  how  soon  after  the  first 
appearance  of  the  symptoms,  he  has  been  obliged  to  keep  his  bed. 

All  commemorative  circumstances  are  highly  important  in  diag- 
nosis :  in  many  diseases,  indeed,  and  particularly  in  those  whose 
diagnosis  is  somewhat  obscure,  it  is  quite  as  much  upon  the  suc- 
cession of  antecedent  symptoms,  as  upon  the  concurrence  of  those 
actually  present,  that  the  physician's  opinion  may  be  founded. 
Unfortunately,  many  patients  are  not  in  a  condition  to  give  a  clear 
statement  of  previous  occurrences,  and  the  physician  is  deprived 
of  the  information  which  might  have  been  supplied  by  an  accu- 
rate relation.  When  the  patient's  age  or  the  disturbance  of  his 
intellectual  faculties  unfit  him  for  replying  to  our  questions,  we 
must  rely  upon  the  attendants. 

3.  When  all  the  preceding  details  are  known,  we  pass  to  the 
26 


302  DIAGNOSIS. 

examination  of  the  existing  symptoms,  which  generally  supply  the 
most  important  diagnostic  signs. 

We  first  inquire  if  the  patient  has  any  pain  ;  if  so,  we  ascertain 
its  situation.  We  should  not  rest  satisfied  with  knowing  that  it  is 
seated  in  the  stomach  or  in  the  cardiac  region,  etc. ;  the  vague  sense 
of  these  expressions,  as  employed  by  persons  unacquainted  with 
medicine  is  too  well  known  :  we  request  the  patient  to  point  out 
with  his  hand  the  place  where  the  pain  is  seated,  and  also,  if  it 
extend  over  a  considerable  surface,  to  circumscribe  it  and  trace  its 
course  ;  we  inquire  if  it  is  superficial  or  deep-seated,  continued,  pe- 
riodical or  transient ;  if  its  intensity  be  uniform,  or  if  it  increase  and 
diminish  at  intervals,  and  under  what  influences ;  if  it  be  accom- 
panied by  a  sensation  of  heat  or  cold,  of  weight,  etc. ;  we  ascer- 
tain thoroughly  the  effect  of  pressure  upon  this  pain,  and  ask  the 
patient  to  what  it  may  be  compared. 

We  next  notice  whether  there  is  any  change  in  the  color,  vol- 
ume, form  and  consistence  of  the  affected  part.  This  examination 
often  requires  the  concurrence  of  the  sight  and  touch ;  it  should  be 
made  with  the  most  scrupulous  attention,  and  can  never  be  omit- 
ted without  disadvantage.  We  also  ascertain  if  any  unusual  pul- 
sation or  fremitus  exist  in  the  painful  part,  and,  in  certain  cases, 
whether  the  natural  resonance  on  percussion  is  preserved. 

The  three  great  splanchnic  cavities  present  very  different  condi- 
tions in  regard  to  exploration,  relative  to  the  various  degrees  of  re- 
sistance offered  by  their  envelopes,  and  also  to  the  number  and 
importance  of  their  contained  viscera.  The  cranial  cavity  being 
entirely  surrounded  by  osseous  walls,  the  enclosed  parts  are,  as  we 
may  say,  removed  from  our  explorative  means,  and  protected  also 
from  the  action  of  external  objects  likely  to  prove  injurious.  It  is 
in  early  infancy  only,  or  from  the  results  of  diseases  which  have 
retarded  ossification,  or  more  or  less  completely  destroyed  a  por- 
tion of  the  bony  parietes  of  the  encephalon,  either  suddenly  or 
gradually,  that  the  physician  can  see  and  touch  the  organs  within, 
naturally  inaccessible  to  direct  explorative  means,  and  whose  dis- 
eases we  can  only  appreciate  from  the  supervening  functional  dis- 
turbance; the  difficult  diagnosis  of  cerebral  disease  is  thus  ex- 
plained, a  diagnosis  so  difficult,  that  notwithstanding  the  very 
remarkable  works  published  upon  this  subject  during  the  last 
twenty  years,  the  physician  who  does  not  wish  to  hazard  his  opin- 
ion, is  frequently  obliged  to  be  extremely  reserved  in  regard  to  the 
diagnosis  of  a  cerebral  affection,  given  at  the  patient's  bedside. 
This  uncertainty,  however,  does  not  ordinarily  regard  the  existence 
of  the  lesion,  but  its  peculiar  form;  the  cranium,  containing  but  a 
single  viscus  and  its  enveloping  membranes,  presents  in  this  re- 
spect favorable  conditions  for  diagnosis,  which  compensate,  in  some 
measure,  for  the  difficulties  resulting  from  the  arrangement  of  the 
investing  tissues. 

The  thoracic  parietes,  formed  both  of  osseous  and  soft  parts,  are 
so  disposed,  that  while  they  prevent  the  application  of  some  of  our 
direct  means  of  exploration  to  their  contained  organs,  they  still 


DIAGNOSIS.  303 

admit  many,  by  whose  aid  we  can  appreciate,  and,  as  it  were,  touch, 
the  greater  part  of  the  material  organic  lesions :  they  are  suscepti- 
ble of  dilatation  and  contraction,  either  complete  or  limited,  and 
these  changes  of  volume  afford  us  some  valuable  signs.  But  while 
exploration  of  this  region  meets  with  fewer  obstacles,  the  greater 
number  of  contained  organs  renders  it  more  difficult  to  determine 
the  seat  of  the  disease. 

Lastly,  the  nature  of  the  abdominal  parietes  which  are  formed 
posteriorly  by  the  bony  column  which  supports  the  trunk  of  the  body, 
and  elsewhere  by  fleshy  tissues,  renders  every  kind  of  exploration 
possible.  But  the  number  of  organs  contained  in  this  cavity  is  far 
greater  than  in  the  two  others :  many  among  them  concur  in  the 
same  function,  and  from  this  very  fact,  the  determination  of  the 
seat  of  disease  presents  more  difficulties  and  is  more  frequently  un- 
certain. We  shall  summarily  state  the  proper  method  of  examin- 
ing each  of  these  three  great  cavities,  either  as  a  whole  or  in  re- 
gard to  any  of  their  component  parts. 

A.  If  the  head  be  affected,  it  is  sometimes  useful  to  examine  that 
portion  of  the  cranium  where  the  pain  is  felt,  to  ascertain  if  there 
be  any  partial  tumefaction,  and  particularly,  oedema  and  tender- 
ness of  the  scalp,  characteristic  signs  of  erysipelas  of  this  part; 
also  if  the  bony  parietes  be  intact,  if  the  sutures  are  in  their  natural 
condition,  etc. 

We  shall  not  attempt,  in  this  place,  to  review  all  the  symptoms 
which  may  be  presented  by  the  numerous  organs  enclosed  within 
the  cranium  or  situated  upon  the  face.  We  shall  restrict  ourselves 
to  the  statement,  that  pain  in  the  head  and  certain  grave  functional 
disorders  of  the  encephalon,  as  delirium  and  convulsions,  are  far 
more  frequently  the  indication  of  lesions  in  organs  more  or  less  re- 
mote, or  the  effect  of  certain  deleterious  agents,  among  which 
should  be  mentioned  the  virus  of  eruptive  fevers,  than  the  result 
of  actual  cerebral  disease.  We  shall  hereafter  reconsider  this  point 
when  treating  of  sympathetic  phenomena,  considered  in  their  rela- 
tion to  diagnosis. 

At  present  we  merely  observe,  that  pain,  when  confined  to  the 
right  or  left  side  of  the  head,  hemicrania,  properly  so  called,  is 
almost  constantly  owing,  either  to  a  lesion  of  the  corresponding 
cerebral  hemisphere,  or  of  its  membranes,  or,  far  more  frequently, 
to  disease  of  some  of  the  parts  included  in  the  same  half  of  the 
face,  particularly  the  nasal  fossas.  the  frontal  and  maxillary  sinu- 
ses, the  teeth,  the  ear,  or  the  eye. 

B.  When  the  vertebral  column  is  the  seat  of  pain,  or  when  re- 
markable disturbance  of  the  nervous  action  of  the  spinal  marrow 
directs  attention  to  that  point,  the  spinal  region  should  be  exam- 
ined, the  patient  either  standing,  or  lying  upon  the  abdomen.     We 
are  thus  enabled  to  discover  the  various  deviations  and  curvatures 
of  which  the  spine  may  be  the  seat,  the  projection  of  one  or  more 
vertebrae  accompanying  Pott's  disease,  etc.     Great  importance  has, 


304  DIAGNOSIS. 

of  late,  been  attached  to  the  pain  (more  or  less  severe)  produced  in 
a  limited  portion  of  the  vertebral  column  by  pressure,  made  suc- 
cessively, with  one  or  two  fingers  from  the  atlas  to  the  sacrum,  and 
this  phenomenon  has  been  cited  as  capable  of  revealing  the  ex- 
istence of  a  lesion  of  the  spinal  marrow,  or  of  its  membranes,  in  the 
part  corresponding  to  the  seat  of  pain.  The  thickness  of  the  parts 
comprised  between  the  spinous  processes  and  the  spinal  marrow, 
the  slight  depression1  ity  of  the  vertebrae,  and  the  unequal  projec- 
tion of  the  different  spinous  processes,  lead  us  to  suppose  that  the 
importance  of  this  sign  has  been  much  exaggerated,  and  that  new 
facts  are  necessary  in  order  to  determine  its  value.  The  same 
may  be  said  of  the  hot  sponge  which  Copeland  *  has  proposed  to 
pass  along  the  spine,  and  which,  it  is  asserted,  would  cause  a 
burning  sensation  in  that  point  only  where  the  medulla  was  af- 
fected. 

C.  If  the  ear  be  painful,  or  if  any  remarkable  lesion  of  the  audi- 
tory sense  arrest  the  physician's  attention,  the  meatus  auditorius 
externus  should  be  examined,  and  in  certain  cases,  it  should  be 
ascertained  whether  the  meatus  auditorius  internus  be  permeable. 

The  examination  of  the  meatus  auditorius  externus  is  not  very 
difficult ;  it  is  often  sufficient  to  straighten  the  passage  by  draw- 
ing the  concha  upwards  and  outwards,  and  thus  gain  a  complete 
view  of  the  whole  internal  surface,  and  even  distinguish  with  suf- 
ficient precision  the  membrane  of  the  tympanum,  especially  if 
direct  solar  light  be  introduced.  If  simple  traction  of  the  concha 
be  not  sufficient  to  bring  the  interior  of  the  auditory  canal  properly 
into  view,  we  employ  the  small  instrument  called  speculum  auris, 
whose  two  movable  blades,  separating  after  their  introduction, 
straighten  and  enlarge  the  passage,  and  allow  the  eye  to  distinguish 
the  different  changes  occasioned  by  disease,  either  in  the  mem- 
brane itself,  or  in  the  matter  secreted  by  it ;  ulcerations  and  perfo- 
rations of  the  tympanum  are  equally  easy  of  discovery  by  means  of 
this  instrument. 

Exploration  of  the  meatus  auditorius  internus,  which  has  been 
icvived  by  the  exertions  of  Dr.  Deleau,  presents  considerable  dif- 
ficulty; on  this  account  it  is  hardly  ever  employed,  except  by  the 
small  number  of  physicians  who  make  the  diseases  of  the  ear,  and 
their  treatment,  the  object  of  special  study.  This  exploration  is 
performed  by  means  of  a  small  sound  of  metal,  or  preferably,  of 
gum  elastic,  introduced  into  the  nasal  fossae  and  directed  so  as  to 
penetrate  into  the  Eustachian  tube.  The  obliteration  of  this  canal 
is  a  frequent  cause  of  deafness. 

D.  Certain  peculiar  phenomena,  as  the  nasal  alteration  of  the 
voice,  difficulty  of  breathing  through  the  nose,  discharge  of  puru- 
lent or  sanious  matter  from  the  anterior  or  posterior  openings  of 

*  Observations  on  the  Symptoms  and  Treatment  of  Diseases  of  the  Spine.  Lon- 
don, 1815. 


DIAGNOSIS.  305 

the  nasal  fossae,  or  a  fetid  odor  proceeding  from  these  cavities,  may 
require  an  examination  which  is  managed  as  follows  :  the  patient 
is  turned  towards  the  light,  the  head  thrown  backwards,  one  of  the 
examiner's  fingers  pressed  upon  the  lobe  of  the  nose  for  the  pur- 
pose of  expanding  the  nostrils,  or,  preferably,  a  pair  of  dressing 
forceps  is  introduced,  the  separation  of  whose  branches  allows  of 
a  more  complete  inspection  of  these  anfractuous  cavities.  We 
may,  moreover,  by  means  of  an  elastic  sound,  or  of  Belloc's  instru- 
ment, sometimes  ascertain  the  presence  of  a  foreign  body  not  dis- 
cernible by  the  eye. 

E.  If  the  disease  occupy  the  isthmus  of  the  fauces,  or  the  supe- 
rior opening  of  the  larynx  or  oesophagus,  the  following  is  the  mode 
of  examination. 

1.  For  the  examination  of  the  isthmus  of  the  fauces,  we  cause 
the  patient  to  open  the  mouth  widely  :  we  depress  the  tongue  with 
the  index  finger,  with  the  handle  of  a  spoon,  a  spatula  or  the  in- 
strument called  tongue  depressor  *  whose  concave  surface  is 
accurately  adapted  to  the  convexity  of  this  organ,  and  we  expose 
the  velum  palati  and  its  pillars,  the  uvula,  tonsils  and  posterior 
part  of  the  pharynx.  In  some  persons,  the  epiglottis  itself  may  be 
seen  behind  the  base  of  the  tongue,  and,  when  inflamed,  may  come 
entirely  into  view,  resembling  a  cherry  with  a  median  fissure. 

We  ascertain  the  alterations  in  these  various  organs,  in  respect  to 
color,  volume,  moisture  or  dryness,  the  nature  of  their  secretions, 
the  coats  or  false  membranes,  granulations,  liberations,  and  perfo- 
rations which  they  may  present.  Certain  individuals  have  the 
faculty  of  lowering  the  base  of  the  tongue  sufficiently,  by  muscular 
action  alone,  to  expose  completely  those  parts  not  visible  in  the 
majority  of  persons  except  by  powerful  depression  of  that  organ; 
in  them  the  inspection  of  the  posterior  fauces  is  as  easy  as  that 
of  the  gums  and  tongue. 

Some  diseases,  as  angina  tonsillaris  and  mercurial  stomatitis, 
when  at  their  height,  entirely  prevent  the  depression  of  the  lower 
jaw,  and,  consequently,  completely  frustrate  this  kind  of  explora- 
tion. In  these  cases,  where  the  lesions  cannot  be  seen,  we  some- 
times succeed  in  ascertaining,  although  with  difficulty,  by  means 
of  the  index  finger  introduced  into  the  mouth,  between  the  slightly 
separated  teeth,  or  in  a  space  where  they  are  wanting,  increased 
volume  of  the  tonsils,  and  their  consistence,  and  occasionally  to  dis- 

*  The  speculum  oris  (lately  constructed  by  the  French  instrument^makers)  com- 
bines the  speculum  with  the  depressor  lingua.  ;  it  consists  of  the  latter,  projecting 
from  a  hoop  of  the  same  metal,  (usually  the  German  silver,  or  the  amalgam 
called  "  maillechort,")  which  is  pierced  with  two  or  three  apertures  correspond- 
ing to  the  sams  number  of  buttons  for  retaining  it  at  different  graduations  of  its 
circumference,  thus  adapting  it  to  the  various  sizes  of  the  mouth  in  different  indi- 
viduals, and  maintaining  it  permanently  expanded  during  its  insertion,  thereby 
avoiding  the  signal  inconveniences  experienced  when  a  spatula  or  the  handle  of  a 
spoon  are  used  for  depressing  the  tongue.  A  far  better  view  of  the  buccal  cavity 
and  posterior  fauces  is  also  obtained.  —  TRANS. 

26* 


306  DIAGNOSIS. 

cover  an  abscess,  which  has  in  some  instances  been  ruptured  by 
simple  pressure  of  the  finger. 

By  means  of  the  finger  introduced  as  far  as  possible  into  the 
mouth,  in  certain  cases  of  angina  cedematosa  [oedema,  of  the  glot- 
tis\,  we  discover  the  tumefaction  of  the  membranous  folds  extend- 
ing from  the  epiglottis  to  the  arytenoid  cartilages  and  circumscrib- 
ing the  superior  opening  of  the  larynx.  This  examination  excites 
in  some  patients  so  strong  contraction  of  the  pharyngeal  muscles 
and  so  much  retching,  that  it  is  wholly  useless. 

Exploration  of  the  oesophagus  and  of  that  portion  of  the  pharynx 
not  attainable  by  the  finger,  must  be  practised  with  the  cesopha- 
geal  tube,  which  is  introduced  through  the  nasal  fossae,  or  prefera- 
bly, by  the  mouth.  We  thus  discover  or  suspect,  in  some  cases, 
from  the  degree  of  resistance  encountered,  the  existence  of  stricture 
or  the  presence  of  a  foreign  body,  and  determine  their  situation. 

F.  When  local  symptoms  are  manifested  in  the  chest,  we  should 
endeavor  to  determine  whether  the  disease  occupies  the  parietes  of 
the  thorax,  or  the  organs  contained  within  it,  and  in  the  latter  case, 
whether  it  be  seated  in  the  organs  of  respiration  or  circulation. 
To  obtain  this  result,  the  conformation  of  the  chest  should  be  ex- 
amined (p.  91),  and  percussion  and  auscultation  employed,  to  ascer- 
tain whether  the  functional  disturbance  is  connected  with  some 
material  alteration  of  the  organs  contained  in  this  cavity,  and  if 
necessary,  to  these  results  should  be  added  those  obtained  by  men- 
suration. We  have  previously  mentioned  the  signs  furnished  by 
each  of  these  modes  of  exploration ;  we  will  here  enumerate,  very 
briefly,  the  diagnostic  signs  acquired  by  the  comparison  of  these 
three  orders  of  phenomena. 

The  diminution  or  permanent  absence  of  the  respiratory  mur- 
mur, without  alteration  either  of  the  conformation  or  resonance  of 
the  chest,  usually  indicates  that  some  internal  or  external  body 
closes  or  compresses  the  trachea,  and  prevents  the  passage  of  air 
into  the  pulmonary  vesicles.  According  as  these  phenomena  man- 
ifest themselves  in  a  limited  portion,  or  over  the  entire  surface 
of  one  side  of  the  chest,  or  even  of  both,  we  conclude  that  the 
obstruction  to  the  passage  of  air,  occupies,  in  the  first  case,  one  of 
the  bronchial  divisions ;  in  the  second,  the  principal  bronchus ;  in 
the  third,  the  trachea  or  larynx. 

If  the  diminution  in  the  strength  of  the  respiratory  murmur  be 
accompanied  by  increased  resonance  and  dilatation  of  the  thoracic 
parietes ;  if  these  phenomena  are  particularly  manifest  in  the 
space  included  between  the  clavicle  arid  the  mamma,  their  con- 
currence reveals  the  existence  of  pulmonary  emphysema. 

Entire  absence  of  the  respiratory  murmur  over  one  side  of  the 
chest,  with  tympanitic  resonance  and  dilatation  of  the  parietes, 
generally  indicates  the  existence  of  pneumo-thorax.  If  amphoric 
respiration  and  voice  be  added  to  the  three  previously  mentioned 
phenomena,  we  can  no  longer  doubt  that  there  is  a  communication 
between  the  pleural  cavity  and  some  bronchial  branch,  from  which 


DIAGNOSIS.  307 

communication  pneumo-thorax  results.  If  metallic  tinkling  and 
gurgling  on  succussion  be  added  to  the  former  symptoms,  and  if 
the  sound  become  flat  at  the  base  of  the  chest,  over  a  space  grad- 
ually extending  upwards,  hydro-pnenmo-thorax  undoubtedly  ex- 
ists. 

If  we  find  simultaneous  diminution  of  resonance  and  feebleness 
or  absence  of  the  respiratory  murmur,  there  is,  necessarily,  either 
alteration  of  the  pulmonary  parenchyma,  rendering  it  less  per- 
meable to  the  air,  or  interposition  of  some  solid  or  fluid  body, 
which  prevents  both  the  transmission  of  the  respiratory  murmur, 
and  also  the  penetration  of  air  into  the  compressed  lung. 

If  the  sound  be  flat  over  one  entire  side  of  the  chest,  if  the  res- 
piratory murmur  and  the  resonance  of  the  voice  be  null  in  that 
part,  there  is  certainly  liquid  effusion  into  the  pleural  cavity,  par- 
ticularly if  mensuration  discloses  a  remarkable  increase  or  dimi- 
nution of  volume  in  the  affected  side ;  in  the  latter  case,  absorption 
of  the  fluid  is  taking  place.  If  the  sound  be  obscure  or  flat  in  one 
part  of  the  chest  only,  the  corresponding  changes  are  generally 
less  marked,  and,  when  present,  almost  always  imply  an  organic 
lesion  of  a  chronic  nature.  If  this  obscurity  of  sound  be  at  the 
superior  part  of  the  chest,  and  in  the  sub-clavicular  region  espe- 
cially, if  there  be  a  depression  in  that  point  more  readily  appreci- 
able by  the  eye  than  by  mensuration,  if  the  respiratory  murmur 
be  feeble,  expiration  prolonged  and  somewhat  rude,  and  particu- 
larly if  some  moist  crepitus  be  heard,  if  the  voice  is  more  resonant 
there  than  on  the  opposite  side,  we  must  conclude  that  tubercular 
affection  of  the  lungs  exists.  The  flat  sound,  accompanied  by 
bronchial  respiration  and  resonant  voice,  may  depend  upon  pul- 
monary induration  or  slight  pleuritic  effusion.  In  these  two  cases, 
mensuration  is  of  no  service,  but  generally,  the  resonance  of  the 
voice  has  a  jerking  character  in  pleurisy ;  the  contrary  is  the  case 
in  pneumonia.  In  the  latter  affection,  some  crepitus  is  nearly 
always  caused  by  the  cough,  in  certain  points  where  bronchial 
respiration  is  heard,  and  this  constitutes  a  valuable  diagnostic 
sign.  Partial  pleuritic  effusion  constantly  occupies  the  lowest  part 
of  the  chest ;  pneumonia  may  be  manifested  in  any  portion. 

Dulness  on  percussion,  with  absence  of  respiratory  murmur  and 
resonance  of  voice,  when  limited  to  any  part  of  the  chest  except 
the  praecordial  region,  almost  always  denotes  a  circumscribed 
pleuritic  effusion,  the  fluid  being  in  moderate  quantity  (d*  une 
ccrtaine  epaisseur)  ;  sometimes,  a  tumor  or  partial  splenization  of 
the  lung. 

Circumscribed  and  chronic  effusion,  and  tumors,  may  cause  a 
partial  protrusion  or  prominence  of  the  thoracic  parietes,  which  is 
never  produced  by  splenization.  Tumors  are  almost  always  seated 
in  the  superior  portion  of  the  chest;  most  frequently  they  are 
formed  by  the  dilatation  of  the  large  vessels ;  they  then  present 
pulsations  isochronous  with  those  of  the  heart,  abnormal  sounds 
and  other  characteristic  signs.  The  distinction  between  circum- 
scribed effusion  and  pulmonary  splenization  is  often  difficult :  but 


308  DIAGNOSIS. 

in  one  case,  the  possibility  of  changing  certain  conditions  relating 
to  the  effusion  by  varying  the  attitude  of  the  patient,  and  the 
moderate  intensity  of  the  dyspnoea  and  febrile  action ;  in  the  other, 
(splenization,)  the  presence  of  pneumonic  sputa  and  the  gravity 
of  the  general  symptoms  are  phenomena,  which,  in  most  cases,  will 
supply  the  deficiency  of  signs  furnished  by  exploration  of  the 
chest ;  effusion,  moreover,  constantly  occupies  the  base  of  the  chest ; 
splenization  may  occur  in  any  portion. 

A  flat  sound  on  percussion,  when  confined  to  the  cardiac  region, 
indicates  an  affection  of  the  heart,  or  of  its  envelopes.  We  should 
suspect  pericarditis,  if  the  affection  be  recent,  if  the  dulness  has 
been  rapidly  developed,  if  the  sounds  of  the  heart  are  deep  and 
obscure;  if  opposite  phenomena  are  observed,  our  diagnosis  should 
be  hypertrophy,  particularly  if  there  be  also  considerable  promi- 
nence of  the  prsecordial  region,  strong  impulse  and  very  distinct 
bellows  murmur. 

G.  When  the  symptoms  are  referred  by  the  patient  to  the  ab- 
domen, that  part  should  be  thus  examined.  The  patient  should 
assume  the  dorsal  decubitus,  the  head  be  raised  by  a  pillow,  the 
thighs  flexed  upon  the  pelvis,  the  legs  upon  the  thighs,  and  the 
knees  slightly  separated.  We  ascertain  by  ocular  inspection,  or 
by  means  of  the  hand,  the  changes  of  form  and  volume  which 
may  be  presented,  either  over  the  entire  surface  of  the  abdomen, 
or  in  one  or  more  points,  especially  in  those  where  hernia  or  simple 
dilatation  of  herniary  apertures  may  exist.  Pressure  and  palpa- 
tion are  next  resorted  to,  conformably  to  the  foregoing  rules ;  we 
percuss,  and  if  necessary,  employ  mensuration  and  touch,  should 
any  circumstance  indicate  the  utility  of  these  explorative  means. 
In  those  cases  where  the  abdomen  is  distended  by  an  enormous 
quantity  of  serous  fluid,  it  often  happens  that  we  cannot  exactly 
judge  of  the  condition  of  the  viscera,  or  discover  the  lesion  which 
causes  the  dropsical  effusion  until  after  the  evacuation  of  the  fluid 
by  tapping. 

Many  important  diagnostic  signs  are  furnished  by  abdominal 
exploration.  It  alone,  enables  us  to  ascertain  the  accumulation  of 
serous  fluid  in  the  peritoneum,  of  gas  in  the  intestines,  and  the 
various  tumors  resulting  from  hypertrophy  or  degeneration  of  the 
abdominal  viscera.  The  latter  are  characterized  by  certain  con- 
ditions with  which  we  should  be  acquainted,  because  they  consti- 
tute actual  pathognomonic  signs ;  thus,  the  liver  arid  spleen  almost 
constantly  preserve  their  original  form  in  the  different  diseases 
which  augment  their  volume,  and  no  other  part,  when  morbidly 
enlarged,  assumes  the  form  of  the  liver  or  spleen;  consequently, 
whenever  we  discover  in  the  abdomen,  a  tumor  occupying  the 
right  hypochondriac  and  the  epigastric  region,  extending  upwards 
beneath  the  ribs,  and  whose  inferior  border  is  firm,  angular,  run- 
ning transversely,  but  more  often  obliquely,  from  left  to  right,  and 
from  above  downwards,  we  may  be  sure  that  it  is  formed  by  the 
liver.  A  tumor  which  occupies  the  left  side,  extending  somewhat 


DIAGNOSIS.  309 

beyond  the  false  ribs,  whose  form  is  a  segment  of  an  ovoid,  whose 
internal  border  is  rounded  and  angular,  and  vertical  in  its  direc- 
tion, must  be  formed  by  the  spleen,  particularly  if  no  general 
transposition  of  the  viscera  exist,  of  which  an  examination  of  the 
praecordial  region  may  convince  us :  if  the  heart  be  in  its  usual 
situation,  we  may,  as  a  general  rule,  conclude  that  the  liver  and 
the  spleen  are  so,  likewise.  The  bladder  in  both  sexes,  the  uterus, 
and,  to  a  certain  extent,  the  ovary  in  the  female,  present  in  their 
development,  certain  peculiarities  of  form  and  position,  which 
admit  of  easy  recognition,  at  least  in  the  majority  of  cases.  Tu- 
mors formed  by  masses  of  faecal  matter  in  the  large  intestines, 
have  a  form  similar  to  a  string  of  beads  {forme  de  chapelet), 
which  generally  renders  their  diagnosis  easy.  Those  formed  by 
the  kidneys  have  no  peculiar  shape,  and  the  depth  at  which  they 
are  seated,  does  not  allow  us  to  reach  them,  except  they  have 
acquired  considerable  volume.  We  may  discover  these  tumors  by 
seizing  the  sub-costal  region  with  the  whole  hand,  the  thumb 
resting  upon  the  lumbar  portion,  and  the  fingers  upon  the  side. 
Tumors  developed  in  the  stomach  and  intestines  are  never  uniform 
in  volume,  form  or  seat,  and  are  frequently  movable.  Those 
of  the  pylorus  are  found,  in  certain  patients,  very  far  from  the 
region  commonly  occupied  by  this  extremity  of  the  stomach  ;  they 
have  occasionally  been  discovered  near  the  umbilicus,  and  even  in 
the  right  iliac  fossa,  nearly  in  contact  with  the  anterior,  superior 
spinous  process  of  the  ilium.  The  iliac  fossae  are  very  frequently 
the  seat  of  phlegmonous  tumors,  to  which  the  attention  of  physi- 
cians has  been  particularly  directed  by  the  researches  of  Dance, 
and  MM.  Melier,  Meniere  and  Grisolle.  Lastly,  the  abdomen  is 
sometimes  the  seat  of  pulsative  tumors,  some  of  which  are  formed 
by  aneurismal  arteries,  others  derive  their  pulsation  from  a  neighbor- 
ing artery.  Auscultation  should  be  practised  in  these  cases,  as  well 
as  in  those  where  there  is  doubt  as  to  the  existence  of  pregnancy. 
It  is  also  interesting  (as  is  evident  from  the  researches  of  many 
English  physicians,  particularly  Bright,  Corrigan,  Beatty  and 
Stokes  )  in  certain  forms  of  peritonitis,  especially  in  those  where 
the  abdomen  contains  a  more  or  less  resistant  tumor;  in  these 
cases  a  slight  friction  sound  is  heard,  indicative  of  the  develop- 
ment of  false  membranes  upon  the  internal  surface  of  the  peri- 
toneum. 

H.  In  scrotal  examinations,  it  is  important  to  ascertain  whether 
the  disease,  whatever  be  its  nature,  occupies  the  envelope  or  the 
contained  organs,  and  among  the  latter,  whether  the  epididymis, 
testicle  or  tunica  vaginalis  are  affected ;  to  pressure  and  palpation, 
should  be  added  the  weight  [act  of  weighing,  " ponderation"  ]  of 
the  tumor,  and  we  should  ascertain  particularly,  whether  it  be 
transparent,  by  placing  it  before  a  bright  light ;  tumors  of  the 
testicle  are  heavy  and  opaque,  hydrocele  is  light  and  transparent; 
an  explorative  puncture  (as  it  is  called)  is  sometimes  indispensa- 
ble, to  render  the  diagnosis  positive,  when  examination  of  the 


310  DIAGNOSIS. 

tumor  will  not  justify  us  in  asserting  that  its  contents  are  fluid. 
In  certain  cases  of  scrotal  enterocele,  percussion  elicits  a  clear 
sound,  and  assists  our  diagnosis. 

I.  In  cases  where  the  rectum  is  the  seat  of  the  local  symptoms, 
in  either  sex,  or  the  organs  of  generation  in  the  female,  ocular 
inspection  is  necessary ;  when  the  disease  is  external,  the  anus  or 
vulva  should  thus  be  examined,  the  soft  parts  which  surround  each 
orifice  being  separated  as  far  as  is  necessary;  when  internal,  the 
finger  or  speculum  should  be  introduced  into  the  rectum  or  vagina, 
according  to  the  rules  and  precautions  previously  indicated. 

J.  The  examination  of  the  limbs  is  not  always  so  simple  as 
we  might,  at  first,  suppose.  Not  to  mention  the  difficulty  of  diag- 
nosis, in  certain  cases  of  fracture  without  displacement  of  the 
fragments,  and  of  some  chronic  dislocations,  we  would  point  out, 
as  worthy  the  attention  of  the  physician,  the  frequently  trifling 
difference  in  the  volume  of  the  limbs,  in  their  length,  contractility, 
sensibility,  heat,  freedom  and  extent  of  motion,  and  in  the  volume 
and  direction  of  the  bones  which  support  them.  Partial  or  general 
swelling  of  the  limbs,  the  various  tumors  of  which  they  are  the 
seat,  either  in  their  continuity  or  contiguity,  and  the  external  lesions 
to  which  they  are  even  more  exposed  than  the  body,  supply  the 
physician  with  numerous  phenomena  to  be  discovered  only  by 
examination  of  the  affected  part. 

Having  finished  the  examination  of  the  region  to  which  the  pain 
is  referred,  we  should  ascertain  the  functional  condition  of  the 
corresponding  parts.  For  example,  if  the  patient  complain  of 
pain  in  the  chest,  we  examine  the  respiration  in  regard  to  its  fre- 
quency, its  equality  and  the  mode  of  dilatation  presented  by  the 
thorax;  we  learn  whether  there  be  cough  ;  and  if  there  be  sputa, 
we  examine  them.  Before  passing  to  general  symptoms,  which 
are  less  interesting,  we  should  ascertain  the  functional  condition  of 
those  organs  more  particularly  sympathizing  with  the  affected 
parts.  Thus,  when  an  acute  pain  in  the  lumbar  region  and  along 
the  course  of  the  ureters,  with  suppression  or  alteration  of  the 
urine,  leads  us  to  suspect  inflammation  of  the  kidney,  the  local 
symptoms  having  been  examined,  we  should  inquire  if  there  be 
retraction  of  the  testicles  and  vomiting,  because  these  two  sympa- 
thetic phenomena  are  important  signs  of  nephritis.  The  same  is 
true  of  vomiting  in  peritonitis,  etc. 

If  the  patient  experience  no  local  pain,  and  complain  only 
of  some  functional  disturbance,  as  cough,  diarrhoea,  partial  debil- 
ity, etc.,  we  first  examine  everything  in  any  way  connected  with 
the  function  principally  involved;  the  general  symptoms  are  after- 
wards considered. 

In  those  cases  were  the  patient  complains  only  of  general  indis- 
position without  particular  pain,  of  universal  derangement  of  the 
functions  without  any  marked  disturbance  of  any  one  in  particu- 
lar, we  examine  them  all  in  the  order  we  have  followed  in  the 
general  account  of  symptoms. 


DIAGNOSIS.  311 

The  physician  should  at  first  direct  his  attention  to  the  expres- 
sion of  the  patient's  physiognomy,  and  to  his  attitude.  He  should 
then  endeavor  to  appreciate  the  muscular  force,  either  by  questions 
or  by  certain  movements  required  of  the  patient.  If  the  voice 
seem  unnatural,  he  learns  from  the  assistants  what  changes  it 
may  have  undergone;  he  afterwards  inquires  into  the  condition  of 
the  various  sensations,  the  moral  affections,  the  character  of  the 
patient,  his  intellectual  faculties,  and  his  sleep;  after  which  he 
examines,  successively,  the  nutritive  functions. 

The  interior  of  the  mouth,  and  particularly  the  tongue,  is  next 
examined ;  the  patient  is  asked  if  he  is  hungry  or  thirsty,  if  degluti- 
tion be  free,  if  he  experience  nausea  or  eructations ;  if  he  still  takes 
food,  and  in  what  quantity,  if  digestion  be  easy,  if  uncomfortable 
sensations,  oppression  or  somnolency  occur  after  eating ;  if  there 
are  borborygmi ;  the  physician  should  ascertain  whether  the  ab- 
domen be  supple,  the  alvine  evacuations  regular,  and  what  is  the 
nature  of  the  excretions.  He  next  notices  the  respiration  and  the 
different  respiratory  acts,  then  the  circulation,  heat,  exhalations, 
and  secretions,  and  finally,  if  it  be  necessary,  inquires  into  the 
state  of  the  generative  functions. 

In  this  complete  review  of  the  functions,  the  physician  should 
endeavor  to  fix  the  period  at  which  each  symptom  appeared,  and 
the  successive  changes  it  has  manifested  from  its  appearance  to 
the  moment  of  examination. 

To  the  examination  of  symptoms,  the  difficult,  and  often  un- 
fruitful, search  for  the  productive  causes  of  disease  should  always 
be  added.  The  knowledge  of  causes,  when  it  can  be  gained,  con- 
firms or  rectifies  diagnosis  in  obscure  cases,  and  is  not  without 
interest  in  others.  Consequently,  we  should  not  neglect  to  ask 
whether  the  affection  whose  nature  we  endeavor  to  determine,  be 
hereditary  or  acquired ;  if  this  be  the  first  attack  or  otherwise  ;  if 
it  be  owing  to  specific  causes  whose  action  is  manifest,  or  to  pre- 
disposing causes,  whose  action  is  uncertain ;  if  it  have  any  con- 
nection with  previous  diseases,  and  what  those  diseases  have  been. 

The  effect  of  remedial  measures  may  also  contribute  to  decide 
our  opinion,  particularly  when  the  disease  under  consideration  is 
of  that  limited  number  arising  from  specific  causes ;  the  specific 
remedy  employed,  becomes,  in  such  cases,  a  sort  of  touch-stone 
which  reveals  their  nature.  This  is  particularly  observed  in 
syphilitic  affections,  and  in  some  obscure  forms  of  intermittent  dis- 
eases. In  these  cases,  arid  in  certain  others  also,  diagnosis  is 
almost  entirely  founded  upon  the  knowledge  of  the  cause  which 
has  produced  the  disease. 

$  IV.  Principal  component  Elements  of  Diagnosis. — If  there  are 
certain  diseases  whose  nature  is  simple  and  whose  effects  are  limited 
to  the  parts  they  occupy,  as  wounds,  or  fractures  not  presenting 
those  conditions  to  which  surgeons  have  quite  improperly  applied 
the  term  complication,  it  is  otherwise  in  most  affections,  especially  in 
those  constituting  the  domain  of  medical  pathology.  Here,  indeed, 


312  DIAGNOSIS. 

the  disease  is  nearly  always  complex  ;  there  is  predominant  lesion 
of  one  organ,  simultaneously  with  lesions  of  all  the  others,  or  at 
least  of  those  more  particularly  connected  with  the  one  principally 
affected.  This  more  or  less  general  disturbance  of  the  organism 
sometimes  precedes  the  local  lesion,  announces  it  and  perhaps  con- 
curs in  preparing  its  development ;  in  other  cases  it  is  associated 
with  it;  both  may  appear  simultaneously.  In  all  these  cases  the 
disease  is  by  no  means  simple,  and  the  physician  who  sees  in  ery- 
sipelas or  pneumonia,  only  the  material  lesion  of  the  skin  or  pul- 
monary parenchyma,  would  not  have  an  accurate  idea  or  a  thorough 
knowledge  of  either  disease  ;  for  such  knowledge  necessarily  com- 
prehends, on  the  one  hand,  the  seat  and  nature  of  the  lesion,  its 
extent  and  degree  of  intensity,  and  on  the  other,  the  accompany- 
ing symptomatic  phenomena,  local  and  general,  their  form,  whether 
acute  or  chronic,  the  presence  or  absence  of  febrile  reaction,  the 
energy  of  that  reaction,  the  period  attained  by  the  disease,  the  pe- 
culiar type  it  assumes,  etc. ;  these  are,  indisputably,  so  many  con- 
ditions constituting  indispensable  elements  of  diagnosis,  arid  should 
be  carefully  examined  in  this  connection. 

When  diagnosis  is  thus  thoroughly  considered,  we  see  how  in- 
complete and  restricted  was  the  opinion  of  certain  physicians  of  the 
anatomico-pathological  school,  who  founded  their  diagnosis  of  dis- 
ease entirely  upon  material  organic  lesions,  so  that,  in  their  opinion, 
every  thing  depended  upon  determining  what  organ  was  affected, 
and  in  what  manner.  The  ancients  were  more  excusable,  when, 
strangers  as  they  were  to  the  knowledge  afforded  by  necroscopy, 
they  saw,  in  disease,  only  the  apparent  functional  disturbance, 
which,  indeed,  they  observed  with  admirable  sagacity. 

A.  Determination  of  the  Seat  of  Disease. — This  includes  several 
questions  which  will  be  successively  considered. 

1.  W  hich  is  the  diseased  organ.  2.  To  what  extent  is  it  affected. 
3.  In  certain  cases,  which  of  its  elementary  tissues  is  particularly 
diseased. 

1.  Which  is  the  diseased  Organ? — The  senses  alone  are  suffi- 
cient, in  a  certain  number  of  diseases,  to  inform  us  which  is  the 
affected  organ ;  in  others  this  knowledge  cannot  be  acquired,  except 
by  the  aid  of  those  signs  which  reason  deduces  from  the  phenom- 
ena furnished  by  the  senses;  in  still  other  cases,  the  seat  of  disease 
remains  obscure  through  life,  and  sometimes  even  after  the  ne- 
cropsy has  afforded  us  the  most  complete  investigation,  and  one 
seemingly  the  most  likely  to  dispel  every  doubt. 

When  the  disease  is  external,  as  herpes  zoster  or  erysipelas,  its 
seat  is  so  evident,  that  unprofessional  individuals  can  perceive  it 
equally  with  the  physician.  The  same  is  true  of  the  numerous 
diseases  of  the  skin,  and  of  the  majority  of  those  seated  near  the 
point  of  union  of  the  skin  and  mucous  membranes  ;  conjunctivitis 
is  recognised  at  sight,  as  also  ulceration  and  puffiness  of  the  lining 
membrane  of  the  mouth,  swelling  of  the  tonsils,  excrescences  de- 
veloped near  the  nostrils,  upon  the  glans  penis,  the  vulva  and 


DIAGNOSIS.  313 

around  the  amis.  We  may,  moreover,  as  regards  the  ascertain- 
ing their  seat  by  means  of  our  senses,  compare  these  diseases  with 
certain  affections  in  which  the  diseased  organ,  originally  out  of 
sight  in  one  of  the  splanchnic  cavities,  as  the  thorax  or  even  the 
cranium,  causes  absorption  of  their  parietes  by  reason  of  its  subse- 
quent morbid  growth,  and  shows  itself  beneath  the  skin.  Fungus 
of  the  dura  mater  and  aneurism  of  the  arch  of  the  aorta,  become, 
in  this  way,  external  diseases.  Certain  diseases  of  the  abdominal 
viscera,  may  also  be  subjected  to  the  touch,  especially  when  they 
occupy  the  liver  or  spleen,  which  organs,  as  we  have  previously 
observed,  almost  always  retain  their  form,  whatever  may  be  their 
increase  of  volume.  As  we  have  elsewhere  remarked,  by  the  in- 
troduction of  the  finger  into  the  vagina  or  rectum  we  ascertain  the 
seat  of  various  affections,  and,  by  the  use  of  the  speculum,  vision 
assists  the  sense  of  touch.  In  nearly  all  cases  of  fracture,  the  de- 
formity of  the  limb,  the  mobility  of  the  fragments  and  the  distinct 
crepitation,  are  all  phenomena  clearly  indicative  of  the  seat  of 
injury. 

There  are.  however,  many  diseases,  particularly  among  those  ap- 
pertaining to  internal  pathology,  where  the  senses  alone  are  insuf- 
ficient to  determine  what  organ  is  affected.  If  the  disease  be  one 
of  that  class  which  are  of  sufficient  severity  to  terminate  occasion- 
ally in  death,  and  which  present  constant  lesions  on  dissection,  the 
comparison  of  the  phenomena  observed  during  life  with  the  lesions 
discovered,  after  death,  in  analogous  cases,  generally  enables  the 
physician  to  declare  without  hesitation  its  seat,  and  the  kind  of 
alteration  presented  by  the  affected  organ.  When,  therefore,  in  an 
unlimited  number  of  cases,  after  a  determinate  series  of  symptoms, 
post-mortem  examination  reveals,  in  the  same  parts  of  the  body,  a 
lesion  of  constant  occurrence,  we  reasonably  conclude,  that  when- 
ever the  same  phenomena  reappear,  we  shall  find  the  same  organ 
similarly  affected. 

There  are,  however,  certain  diseases,  some  of  which  are  severe 
and  others  of  slight  importance,  for  whose  elucidation  pathological 
anatomy  furnishes  us  far  less  assistance.  If  the  individuals  affect- 
ed by  them  die,  either  from  the  actual  disease  or  some  coexistent 
affection,  nothing  is  discovered  explanatory  of  the  previously  ob- 
served phenomena,  either  because  the  accompanying  lesions  are 
not  appreciable  by  our  senses,  or  because  the  requisite  attention 
has  not,  thus  far,  been  devoted  to  researches  of  so  delicate  a  nature. 
Many  individuals  die  instantaneously,  or  in  a  very  short  time,  with 
apoplectic  symptoms,  tetanic  convulsions,  and  hydrophobic  spasms ; 
some  even  die  paralytic,  and  no  lesion  whatever  is  discovered  at 
the  necroscopy.  If  an  individual  affected  with  acute  rheumatism, 
or  some  nervous  disease,  be  attacked  by  another  and  a  fatal  mala- 
dy, in  the  majority  of  cases,  no  appreciable  alteration  is  met  with 
in  the  parts  to  which  the  pain  was  referred.  Necroscopy  has  hith- 
erto proved  insufficient  to  determine  the  seat  of  these  diseases,  and 
certain  notions  upon  this  point  have  been  derived  solely  from  the 
often  contestable  laws  of  physiology. 
27 


314  DIAGNOSIS. 

Physiology  acquaints  us  with  the  functions  proper  to  each  of  our 
organs.  Disorder  of  a  function  leads  us  to  admit  a  certain  lesion 
in  the  organ  to  which  that  function  belongs.  Thus,  when  severe 
pain  occurs  without  swelling,  redness,  or  any  other  appreciable 
change  in  the  affected  part,  we  judge  that  the  disease  is  seated  in 
the  nerves  or  brain,  because  they  are  the  organs  of  sensibility. 
If  this  pain  increase  on  motion,  and  diminish  or  cease  by  rest,  if 
its  intensity  is  constantly  proportionate  to  the  force  of  muscular 
contraction,  we  conclude  that  the  affection  is  seated  in  the  organs 
of  motion,  that  is,  the  muscles.  But  here  there  is  no  absolute 
proof;  the  concurrence  of  the  nerves  and  muscles  being  necessary 
to  motion,  it  is  difficult  to  distinguish  whether  the  disturbing  cause 
be  in  the  muscular  or  nervous  system,  or  in  both  together.  This 
distinction  is  equally  difficult  in  convulsive  diseases,  of  which  the 
muscles  are  the  immediate  agents,  and  in  which  the  nervous  sys- 
tem plays,  incontestably,  a  great  part.  Our  previous  and  future 
remarks  upon  sympathy  will  prove  more  clearly  into  what  error 
we  should  be  led,  if  we  attempted,  in  all  cases,  to  determine  exactly 
which  is  the  affected  organ,  from  functional  disturbance  alone. 

The  difficulty  of  fixing  the  seat  of  diseases  becomes  still  greater  in 
those  characterized  by  general  functional  disturbance,  without  pri- 
mary local  affection.  We  mean  fevers,  and  especially  intermittent 
fevers  ;  for  if  there  still  exist  conflicting  opinions  among  physicians 
in  regard  to  the  constancy  and  value  of  lesions  in  continued  fevers, 
they  are  agreed  in  regard  to  the  impossibility  of  determining  the  seat 
of  disease  in  intermittent  fevers.  The  external  appearance  is 
changed,  the  circulation,  heat,  digestion,  secretions,  sensations, 
sometimes  even  the  intellectual  functions,  respiration,  locomotion 
and  the  voice,  are  simultaneously  affected  for  a  certain  number  of 
hours,  the  disturbance  ceasing  with  the  paroxysm.  Where  in  such 
a  case  is  the  seat  of  disease  ?  Is  it  in  the  spleen,  as  some  assert  ?  In 
the  stomach,  the  intestines,  or  the  mesentery  ?  Is  it  in  the  nervous 
system  generally,  or  in  one  of  its  divisions  ?  In  the  blood  or  some 
other  of  the  fluids  which  enter  into  the  composition  of  the  human 
body?  All  these  opinions  have  had  or  still  have  their  partisans, 
but  none  of  them  has  been  established  upon  a  basis  sufficiently 
firm  to  convince  us  of  its  truth.  The  interesting  researches  in 
pathological  anatomy,  made  some  years  since  by  Dr.  Bailly  (too 
soon  removed  from  science  and  society),  in  a  country  where  inter- 
mittent fevers  are  sufficiently  severe  to  terminate  frequently  in 
death,  have  left  the  question  of  the  seat  of  intermittent  fever  unde- 
cided ;  a  disease  in  all  other  respects  so  well  understood,  that  not- 
withstanding the  obscurity  which  prevails  in  regard  to  this  point 
of  their  history,  it  is,  at  present,  of  all  th^  diseases  to  which  man  is 
subject,  the  one  whose  diagnosis  is  generally  most  easy,  and  whose 
treatment  shows  most  incontestably  the  power  of  our  art.  So  true 
is  it  that  the  most  important  thing  in  medicine,  and  even  in  diag- 
nosis, is  not  always,  as  has  been  asserted,  to  determine  which  is  the 
affected  organ,  and  how  it  is  affected. 

2.   The  Seat  of  the  Disease  being  known>  what  is  its  Extent  ?  — 


DIAGNOSIS.  315 

In  those  cases  where  the  physician  succeeds  in  discovering  which 
is  the  diseased  organ,  it  is  desirable  to  determine  to  what  extent  it 
is  affected.  If  we  consider  how  much  its  extent  influences  the 
gravity  of  the  disease ;  what  difference  there  is,  for  instance,  be- 
tween erysipelas  limited  to  one  cheek,  and  that  which  occupies 
the  face,  and  simultaneously  the  entire  scalp ;  between  partial  pem- 
phigus, and  that  which  is  nearly  general ;  between  variola  discreta 
and  variola  confluens  (for  in  the  latter,  it  is,  as  it  were,  a  simple 
difference  in  the  extent  of  the  affection,  measured  by  the  number  of 
pustules);  between  inflammation  limited  to  a  single  point  in  one 
lung,  and  double  pneumonia;  between  partial  peritonitis,  a  disease 
generally  attended  with  little  danger,  and  general  peritonitis,  which 
is  most  frequently  mortal,  we  cannot  misunderstand  all  the  impor- 
tance which  the  question  of  extent  should  have,  in  deciding  our 
opinion  of  a  disease. 

The  extent  of  those  diseases  which  are  seated  at  the  surface  of 
the  body  is  easily  perceived.  In  these  cases,  however,  the  affec- 
tion is  not  always  confined  to  the  skin.  Many  affections  styled 
cutaneous,  and  particularly  those  depending  upon  a  contagious 
principle,  attack  the  skin  and  certain  of  the  mucous  membranes 
simultaneously,  and.  by  the  febrile  action  they  excite,  often  produce 
lesions  of  considerable  severity  in  the  viscera  themselves. 

It  is  generally  difficult  to  determine  the  extent  of  the  disease  in 
internal  affections ;  this  difficulty,  however,  is  not  always  insur- 
mountable. Thus  the  exploration  of  the  abdomen  often  enables 
us  to  determine  whether  the  liver  is  diseased  throughout,  or  in  one 
lobe  only,  also,  to  what  extent  the  spleen  is  enlarged ;  examination 
of  the  chest  enables  us  to  distinguish  whether  pleuritic  effusion 
occupies  a  part  or  the  whole  of  the  pleura ;  if  pneumonia,  limited 
at  first  to  a  portion  of  the  pulmonary  parenchyma,  invade  daily 
a  greater  extent,  and  whether  at  a  more  advanced  period  it  be- 
comes limited  in  its  seat,  and  diminishes  in  intensity  at  the  same 
time.  Finally,  there  are  certain  cerebral  affections,  haemorrhage 
in  particular,  in  which  we  can,  to  a  certain  extent,  estimate  the 
volume  of  the  apoplectic  clot,  from  the  intensity  of  the  symptoms, 
and  consequently  the  extent  of  the  rupture  of  the  cerebral  pa- 
renchyma. There  is,  then,  a  certain  number  of  internal  diseases, 
in  which  we  can  judge,  approximatlvely  at  least,  of  the  extent 
occupied  by  the  material  lesion. 

3.  The  study  of  the  seat  of  diseases  sometimes  extends  to  de- 
termining which  of  the  elementary  tissues  is  primarily  affected. 
But  we  should  remember  that  this  sort  of  research  belongs  to  that 
molecular  anatomy,  in  which  imagination  too  often  supplies  the 
insufficiency  of  the  senses,  and  whose  results  must  be  received 
with  great  circumspection. 

There  are,  however,  some  diseases  of  the  skin  whose  special  seat, 
whether  in  the  mucous  layer,  or  in  the  follicles,  is  now  scarcely 
contested ;  among  these  are  acne,  which  seems  to  occupy  the  fol- 
licles exclusively,  and  those  affections  known  by  the  name  of  ma- 
culce  and  ephelides,  which,  being  characterized  by  alterations  in  th 


316  DIAGNOSIS. 

color  of  the  skin,  can  hardly  occupy  any  other  part  than  the  mu- 
cous layer,  in  which  the  secretion  of  coloring  matter  takes  place.  — 
Every  one,  at  the  present  day,  is  aware  that  in  typhoid  fever  it  is 
not  the  intestinal  mucous  membrane  which  is  affected,  but  the 
follicles,  either  agminated  or  isolated,  which  lie  between  this  mem- 
brane and  the  cellular  coat,  and  which  occupy  particularly  that 
portion  of  the  ileum  nearest  to  the  caecum.  But  if  we  pass  from 
the  skin  and  mucous  membranes  to  certain  other  organs  in  which 
the  elementary  tissues  are  less  distinct,  as  the  liver,  the  kidney, 
and  even  the  lung;  if  we  wish  to  determine,  in  this  latter  organ, 
the  tissue  in  which  tubercle  is  formed ;  if  we  attempt  to  discover 
in  a  liver  affected  with  cirrhosis,  or  in  a  kidney  affected  with 
Bright's  disease,  the  hypertrophy  of  one  element  of  these  organs 
and  the  atrophy  of  the  other,  we  are  liable  to  leave  the  domain  of 
positive  anatomy,  and  to  enter  upon  a  class  of  questions  which 
are  hardly  susceptible  of  a  definite  solution.  * 

B.  Determination  of  the  Lesion.  —  Having  explained  in  what 
way  the  physician  succeeds  in  discovering  which  is  the  affected 
organ,  and  to  what  extent  it  is  affected,  we  will  now  consider  the 
second  point,  viz.  the  manner  in  which  it  is  affected,  which  compre- 
hends both  the  nature  of  the  lesion  and  the  progress  it  has  made. 

*  The  correctness  of  this  remark  may  be  questioned,  if  we  rightly  understand 
the  author's  assertion.  Can  we  avoid  the  conclusion  that  many  lesions  of  the 
kidneys  have  been  so  accurately  described  by  different  authors,  that  in  respect  to 
them,  we  are  in  "the  domain  of  positive  anatomy,"  and  that  many  questions 
have  received  that  **  definite  solution  "  of  which  they  are  declared  "  insusceptible  " 
in  the  text  ?  The  elaborate  researches  of  Dr.  Bright  upon  the  pathological  lesions 
exhibited  by  the  kidneys,  when  affected  by  the  disease  that  bears  his  name, 
surely  announce  to  us  many  points  within  "  the  domain  of  positive  anatomy."  Dr. 
Prout,  in  his  valuable  work  on  Stomach  and  Renal  Diseases,  declares  that  "  the 
post-mortem  phenomena,  when  studied  in  connection  with  the  condition  of  the 
urine  and  the  constitutional  symptoms,  are  quite  sufficient,  in  a  practical  point  of 
view,  to  regulate  our  proceedings  and  to  show  us  in  general,  what  we  can  and 
what  we  cannot  accomplish." — (p.  178,  4th  English  edition.)  The  admirable 
work  of  M.  Rayer,  from  which  large  quotations  are  made  by  Dr.  Prout,  (loc. 
supra  cit.)  may  be  mentioned  in  proof  of  how  much  "  positive  anatomy  "  can  be 
claimed  at  the  present  time,  in  regard  to  renal  lesions  :  (Traite  des  Maladies  des 
Reins.  Atlas.)  Nothing  can  be  more  minute,  but  at  the  same  time,  what  can  be 
more  accurate,  than  the  description  of  the  morbid  appearances  of  the  kidney  affect- 
ed with  granular  degeneration.1  (Prout.  Op.  cit.  pp.  180,  181.  Rayer's  Post 
Mortem  Classification.)  The  hypertrophied  and  atrophied  tissues  are  clearly  de- 

'This  term,  which  originated  with  DR.  CHRISTISON,  has,  of  late,  been  objected  to  by 
some  authors.  Dr.  WATSON,  in  his  Lectures  on  the  Principles  and  Practice  of  Physic, 
(Vol.  II.  p.  572,  2d  Eng.  edit.)  says,  "  some  call  it  (Bright's  disease)  granular  degenera- 
tion of  the  kidney,  but  the  epithet  granular  is  not  always  applicable."  DR.  COPLAND 
describes  it  under  the  name  of  Cachectic  Nephritis  (Med.  Diet.).  DR.  BRIGHT  himself 
termed  it  granular  disease  of  the  kidneys.  DHS.  Q.UAIN  and  WILLIAMS,  however,  in  their 
late  descriptions  of  the  renal  lesions  observed  in  this  disease,  give,  as  the  second  of  their 
three  divisions,  "  the  truly  granular  or  atrophied  kidney.  (WILLIAMS,  Lond.  Med.  Gaz. 
1845.  QUAIN,  Lond.  Lancet,  Feb.  1846.)  DR.  GEORGE  JOHNSON  has  lately  maintained 
that  the  so-called  granular,  is,  in  fact,  a  "fatty,"  degeneration  of  the  kidney,  analogous  to 
that  of  the  liver."  (Lond.  Lancet,  Jan.  1846.)  GLUGE,  in  his  "  Atlas  der  Pathologischen 


ventured  to  employ  the  term  "  granular  degeneration. 


DIAGNOSIS.  317 

1.  Here,  as  in  the  former  case,  the  disease  may  be  upon  the  sur- 
face of  the  body,  and  then,  by  the  direct  use  of  the  senses,  partic- 
ularly of  sight  and  touch,  we  can  often  recognise  at  once,  both  the 
seat  of  disease  in  the  skin,  in  the  subcutaneous  cellular  tissue,  in 
the  superficial  lymphatic  ganglia,  in  the  mammary  gland  or  in  the 
testicle,  and  its  inflammatory,  scirrhous  or  tuberculous  nature.  If 
the  affection  be  internal,  it  is  in  like  manner  by  the  comparison  of 
all  the  symptoms  of  the  actual  disease,  and  of  the  lesions  observed 
at  necropsies,  in  analogous  cases,  that  we  succeed  in  discovering  the 
nature,  as  well  as  the  seat,  of  the  lesion.  In  the  examination  of  a 
patient  affected  with  pneumonia  or  peritonitis,  for  instance,  the 
physician  cannot  isolate  these  two  questions,  he  perceives  the  seat 
and  nature  of  the  lesion  simultaneously.  This  is  generally  the 
case  ;  the  same  modes  of  investigation  lead  to  the  solution  of  both 
questions,  and  the  solution  of  one  often  implies  that  of  the  other. 
There  are,  however,  frequent  occasions  when  these  two  questions 
become,  at  the  bedside,  entirely  distinct ;  so  that  in  certain  cases, 
the  seat  of  the  lesion  is  evident  and  its  nature  uncertain,  and  vice 
versa.  It  is  quite  common,  for  instance,  to  recognise  satisfactorily  by 
the  peculiar  form  of  a  tumor  developed  in  one  of  the  hypochondria, 
the  existence  of  an  affection  of  the  liver  or  of  the  spleen,  and  not 
be  able  to  determine  the  kind  of  alteration  of  which  those  organs 
are  the  seat.  At  other  times,  the  nature  of  the  lesion  is  manifest 
and  its  seat  obscure  ;  thus,  in  some  cases,  one  of  the  iliac  regions, 
the  right,  for  instance,  becomes,  in  a  short  time,  the  seat  of  an 
acute  pain  which  is  exasperated  by  pressure ;  by  palpation,  a 
resisting,  ill-defined  tumor  is  discovered ;  fever,  nausea  and  vomit- 
fined,  as  also  are  the  periods  when  these  changes  occur  ;  and  although,  with  Dr. 
Proul,  we  may  consider  the  practical  aid  derived  from  the  precise  knowledge  of  post- 
mortem phenomena  as  exhibited  in  the  kidneys,  of  but  little  imponance,  still  they 
are  far  from  valueless,  and  can  by  no  means  be  said  to  constitute  "  an  order  of 
questions  insusceptible  of  definite  solution." 

The  discoveries  of  Kiernan,  while  they  add  so  much  to  our  knowledge  of  the 
anatomy  of  the  healthy  liver,  have  also  tended  to  give  more  minuteness  and  accu- 
racy to  the  details  of  the  pathological  lesions  it  displays.  In  cirrhosis  (which 
is  mentioned  by  M.  Chomel  as  a  disease  in  which  there  can  be  no  precision  in 
regard  to  the  seat  of  lesions  observed  after  death) ,  the  minute  descriptions  of  pathol- 
ogists  seem  to  be  founded  upon  "  positive  anatomy,"  and  if  not  so,  are  worthless. 
The  conclusions  drawn  by  Dr.  Budd  (Diseases  of  the  Liver,  Cirrhosis,  p.  113, 
Eng.  edit.)  in  regard  to  the  appearances  generally  presented  in  cirrhosis,  are  val 
uable  in  support  of  our  position.  He  remarks,  "  The  ordinary  appearances  in 
cirrhosis,  and  the  changes  just  described,  (atrophy  and  diminished  weight  of  the 
liver,  notwithstanding  the  existence  of  an  adventitious  tissue,  formed  of  coagula- 
ble  lymph  ;  and  nodular  formations  composed  of  a  yellow  matter,  seen  by  the 
microscope  to  consist  of  the  original  lobular  substance  of  the  liver,  drawn  into 
these  round  nodules  by  the  previously  mentioned  tissue,)  seem  the  consequence  of 
adhesive  inflammation  in  the  areolar  tissue  about  the  small  twigs  of  the  portal 
vein,  by  which  serum  and  coagulable  lymph  are  poured  out ;  "  etc.  etc.  The  em- 
ployment of  the  microscope  in  these  examinations,  often  explains  problems  pre- 
viously "  insoluble"  (as  is  seen  in  the  above  statement)  and  gives  the  highest  im- 
portance and  daily  increasing  accuracy  to  that  "  molecular  anatomy  where  the 
insufficiency  of  our  senses  is  too  often  supplied  by  the  imagination."  (Vide 
p.  315).  — TRANS. 


318  DIAGNOSIS. 

ing  supervene ;  the  inflammatory  nature  of  the  tumor  is  evident, 
but  where  is  its  peculiar  seat  ?  Is  it  developed  in  the  cellular  tissue 
of  the  iliac  fossa?  Did  it  originate  in  the  coecum?  Might  it  not,  if 
the  patient  be  a  female,  be  seated  in  the  ovary,  rare  as  are  acute 
inflammations  of  that  organ  ?  One  more  example  may  be  cited. 
A  hard,  unequal  tumor,  of  irregular  form,  is  distinguished  through 
the  abdominal  parietes,  near  the  umbilicus;  it  has  supervened 
gradually,  and  its  development  has  been  accompanied  by  progres- 
sive loss  of  flesh  in  the  patient,  whose  hue  is  of  that  straw  color, 
which  appertains  to  a  particular  class  of  organic  diseases ;  no  one 
can  doubt  the  scirrhous  nature  of  the  tumor;  but  how  great  is  the 
difficulty,  in  many  cases,  of  determining  its  seat.  Does  it  occupy 
the  epiploon,  or  certain  mesenteric  glands,  or  the  greater  curvature 
of  the  stomach,  or  some  part  of  the  intestinal  canal?  All  physi- 
cians know  how  embarrassing,  in  these  circumstances,  is  the  deter- 
mination of  its  seat.  In  a  large  proportion  of  cases,  the  uncertainty 
in  regard  to  the  precise  seat  of  the  disease  is  less  dangerous  than 
doubt  as  to  its  nature  ;  for  the  nature  of  the  lesion,  more  generally 
than  its  special  seat,  constitutes  the  basis  of  therapeutical  indica- 
tions. The  treatment  of  pneumonia,  for  example,  differs  generally 
but  very  little  from  that  of  acute  pleurisy,  but  very  much  from  that 
of  pulmonary  tubercle :  in  the  former  case,  the  two  affections  are 
identical  in  their  nature,  and  different  in  their  seat ;  in  the  latter, 
the  seat  is  the  same,  but  the  nature  of  the  lesion  different. 

2.  At  the  same  time  that  the  physician  endeavors  to  determine 
the  kind  of  alteration  presented  by  the  affected  part,  it  is  equally 
important  for  him  to  know  the  degree  attained  by  the  disease. 
An  inflammation  which  has  hitherto  occasioned  simple  turgescence 
of  the  diseased  part,  is  quite  unlike  that  which  has  already  mod- 
ified the  tissues  to  a  great  extent ;  and  this  extensive  modifica- 
tion is  itself  different  from  suppuration ;  scirrhous  induration  dif- 
fers from  ulcerated  cancer,  and  tubercle  exhibits  quite  as  marked 
dissimilarity  in  the  successive  stages  of  its  development.  It  is,  then, 
highly  important  that  the  physician  endeavor  to  appreciate  this 
diagnostic  point,  the  importance  of  which  is  acknowledged  by  all. 
In  external  inflammations,  in  cancerous  affections  of  the  skin,  and 
in  tubercle  of  the  subcutaneous  ganglia,  the  physician  can  easily 
determine  the  degree  the  disease  has  acquired ;  in  internal  diseases 
there  frequently  exist  great  difficulties.  By  the  assistance,  how- 
ever, of  the  progress  made,  especially  of  late,  by  semeiology,  a 
progress  in  which  French  medicine  has  had  the  largest  share,  the 
physician  can  appreciate  during  life,  in  a  considerable  number  of 
visceral  diseases,  the  different  phases  presented  by  the  material 
alterations,  and  determine,  more  or  less  accurately,  the  degree 
they  have  attained.  Enlightened  by  the  signs  supplied  by  the 
various  modes  of  exploration  of  the  chest,  he  is  able  to  ascer- 
tain, in  those,  cases  where  the  disease  is  not  limited  to  the  deep 
seated  portions  of  the  lung,  (and  these  cases  are  the  most  com- 
mon,) whether  the  lung  is  affected  with  simple  inflammatory 
engorgement,  or  whether  it  is  indurated ;  whether  the  tubercles 


DIAGNOSIS.  319 

developed  in  this  organ  are  in  a  crude  or  softened  state ;  he  will 
sometimes  appreciate,  approximatively,  the  extent  of  cavities,  and 
will  easily  recognise  those  cases  where  perforation  of  a  tuberculous 
lung  opens  a  communication  between  the  bronchi  and  the  cavity 
of  the  pleura. 

In  affections  of  the  abdominal  organs,  but  more  particularly  of 
those  contained  within  the  cranium,  the  determination  of  the  degree 
attained  by  the  disease  is  far  more  difficult ;  often  it  is  wholly 
impossible.  There  are,  however,  some  diseases  in  which  the 
physician  may  judge  with  probability  of  the  changes  which  super- 
vene in  the  affected  parts,  from  the  duration  of  the  disease  and  the 
intensity  of  the  symptoms  which  reveal  it.  In  typhoid  fever,  for 
instance,  we  can,  generally,  indicate  at  the  different  periods  of  the 
disease,  the  principal  conditions  of  color,  tumefaction,  and  ulcera- 
tion  presented  by  the  intestinal  follicles  and  mesenteric  glands, 
without  being  able,  however,  to  determine  over  what  extent  of  the 
intestine  and  mesentery  these  lesions  exist.  In  cerebral  haemor- 
rhage, not  sufficiently  severe  to  cause  death,  it  is  not  impossible  for 
the  physician  to  judge  nearly  of  the  changes  which  take  place  in 
the  cerebral  mass  around  the  effused  blood,  and  of  its  definitive 
absorption,  by  the  time  which  has  elapsed,  and  from  the  re-estab- 
lishment of  the  locomotive  function  in  those  parts  which  had  been 
deprived  of  it.  But  in  the  greater  number  of  diseases  which  are 
seated  in  the  abdomen  and  cranium,  and  especially  in  organic 
disease,  we  cannot  determine  the  existing  degree  of  lesion,  the 
favorable  or  unfavorable  changes  which  supervene  in  the  inten- 
sity of  the  symptoms  being  equally  dependent  upon  the  modifica- 
tions presented  by  the  disease,  either  as  regards  its  extent,  or  on 
account  of  its  intensity. 

C.  Symptomatic  Phenomena  considered  in  relation  to  Diagno- 
sis. —  We  cannot  doubt  the  necessity  of  admitting  local  and  general 
functional  disorder,  as  elements  of  diagnosis.  This  necessity  is 
very  evident  in  those  diseases  where  the  physician  cannot  distin- 
guish during  life,  nor  ascertain  after  death,  the  anatomical  lesion 
which  might  account  for  the  symptoms ;  here  the  disease  reveals 
itself  only  by  functional  disturbance ;  it  is  in  the  latter,  alone,  that 
the  physician  can  find  the  elements  of  diagnosis.  But  in  those 
cases,  even,  where  anatomical  lesion  exists,  the  symptomatic  phe- 
nomena are  still  of  great  importance  in  the  appreciation  of  the 
disease.  Compare  pneumonia,  occurring  in  a  young  and  robust 
subject,  and  accompanied  by  that  form  of  febrile  action,  known 
by  the  name  of  inflammatory  fever,  with  the  pneumonia  which 
attacks  an  infirm  and  worn-out  old  man,  which  appears  with 
adynamic  symptoms,  and  we  have,  necessarily,  two  very  different 
diseases,  although  the  anatomical  lesion  may  be  nearly  the  same. 
Compare  acute  with  chronic  inflammation  of  the  stomach ;  there 
are,  in  many  cases,  in  an  anatomical  point  of  view,  but  very  slight, 
and  oftentimes  even  uncertain  differences,  while,  by  their  symp- 
toms, they  constitute  two  entirely  distinct  diseases. 


320  DIAGNOSIS. 

If,  then,  in  diagnosis,  we  did  not  bear  in  mind  the  acute  or 
chronic  form  of  a  disease,  its  character,  or.  as  was  formerly  said, 
the  inflammatory  or  adynamic  nature  which  it  assumes,  we 
should  form  an  inaccurate  idea  of  it,  and  our  diagnosis  would  be 
very  incomplete. 

The  absence  or  presence  of  febrile  action  are  conditions  of  some 
value  in  the  diagnosis  of  many  diseases.  The  complete  absence  of 
fever  is  an  important  sign  in  lead  colic,  and  in  many  nervous  affec- 
tions, as  also,  in  other  cases,  the  presence  of  fever  becomes  an 
important  diagnostic  sign,  in  pneumonia,  for  example,  and  in 
typhoid  fever. 

Independently  of  the  semeiological  value  of  fever,  in  determining 
the  seat  arid  nature  of  the  lesion,  its  existence,  is,  moreover,  of 
great  importance  in  any  single  affection,  as  a  test  of  its  intensity. 
Acute  bronchitis,  for  instance,  is  of  slight  importance  when  entirely 
apyretic ;  it  becomes  more  serious,  if  every  evening  there  be  ac- 
celerated pulse  and  elevated  temperature  ;  it  may  finally  disturb 
the  economy  almost  as  much  as  pneumonia,  when  it  is  associated, 
as  is  not  rare,  with  very  intense  febrile  movement.  In  this  latter 
case,  if  the  patient  be  advanced  in  years,  it  becomes  a  very  dan- 
gerous disease.  The  febrile  state  is.  then,  an  indispensable  condi- 
tion in  the  appreciation  of  certain  diseases,  and  should  form  one 
of  the  elements  of  diagnosis. 

The  period  at  which  the  disease  has  arrived,  is  likewise  an 
indispensable  condition  in  forming  a  medical  opinion.  In  each 
phase  of  the  disease,  the  anatomical  lesion  and  functional  disor- 
ders are  modified  daily,  and  he  would  be  unworthy  the  name  of 
physician,  who,  in  his  appreciation  of  a  disease,  should  disregard 
the  time  already  elapsed,  and  for  whom  pneumonia,  at  the  stage  of 
resolution,  would  not  be  different  from  the  same  disease  at  its  stage 
of  increase :  the  increase  of  the  symptoms  during  the  first  days, 
is  constant  and  regular  ;  but  when  after  the  sixth,  and  much  more 
after  the  eight  or  ninth  day,  the  symptoms  continue  to  become 
aggravated,  the  character  of  the  disease  is  entirely  changed,  and 
the  opinion  formed  upon  the  actual  and  future  state  of  things,  is 
far  more  serious. 

Finally,  the  type  of  the  disease  becomes,  in  certain  circumstan- 
ces, not  only  an  important,  but  the  principal  element  of  diagnosis. 
When  a  certain  affection,  inflammatory,  hsemorrhagic  or  nervous, 
instead  of  appearing  with  a  continued  type,  which  is,  as  it  were,  the 
natural  type  for  most  of  these  affections,  assumes  one  regularly  in- 
termittent, as  the  quotidian,  tertian  or  quartan  ;  when  its  character- 
istic phenomena  appear  and  disappear  alternately,  as  would  be  the 
case  in  regular  intermittent  fever,  with  that  form  of  paroxysm, 
whose  continuance  is  generally  restricted  to  the  limits  peculiar  to  fe- 
brile paroxysms,  the  disease  then  becomes  quite  a  different  thing  from 
inflammation,  haemorrhage,  or  nervous  disease  ;  it  differs  from  them 
by  its  nature  even,  for  it  has  a  different  cause,  progress  and  treat- 
ment, and  it  was  not  without  reason  that  those  who  preceded  us, 
when  describing  these  affections  under  the  ingenious  and  expressive 


DIAGNOSIS.  321 

name  of  masked  fevers*  compared  them  with,  and  at  the  same 
time  distinguished  them  from,  normal  intermittent  fevers.  In  such 
a  case,  as  will  be  evident,  the  type  becomes  in  reality  the  most  im- 
portant diagnostic  condition. 

$V.  Circumstances  which  may  render  Diagnosis  difficult  and 
even,  uncertain.  —  In  the  preceding  sections  we  have  spoken  of  diag- 
nostic signs,  modes  of  exploration,  the  proper  manner  of  examin- 
ing patients,  and  the  principal  elements  of  diagnosis.  It  remains 
for  us  to  glance  at  those  circumstances  which  render  diagnosis 
difficult  and  uncertain,  and  to  indicate,  summarily,  the  course 
which  should  be  pursued  in  order  to  surmount  these  obstacles, 
and,  according  to  circumstances,  pronounce  or  delay  our  opinion.— 
These  obstacles  relate  principally  to  the  epoch  at  which  the  phy- 
sician is  called  to  the  patient,  to  the  predominance  of  general  or 
sympathetic,  over  local  phenomena,  to  the  absence,  even,  of  the 
latter,  to  the  infrequency  of  the  disease  observed,  to  the  complica- 
tions, and  to  deception  on  the  part  of  the  patient. 

1.  Difficult  Diagnosis  on  account  of  the  Period  at  which  the  Phy- 
sician is  summoned. —  When  the  physician  is  called  at  the  com- 
mencement of  an  acute  disease,  it  is  often  difficult,  sometimes  im- 
possible, for  him  to  know  what  it  will  be.  The  invasion  of  certain 
thoracic  inflammations,  is  marked  by  phenomena  of  which  the 
stomach  and  brain  are  the  seat,  as  vomiting  and  delirium,  and  some- 
times the  first  disturbance  of  the  respiratory  functions  does  not 
commence  until  the  second  or  third  day.  The  physician  is  doubt- 
less excusable  in  these  cases,  when  he  fails  to  distinguish  pneumonia 
which  is  not  manifested  by  any  symptom  peculiar  to  that  affection. 
Even  in  these  circumstances,  when  the  disease  has  commenced 
with  that  intense  chill  which  belongs  to  pneumonia  more  particu- 
larly than  to  most  other  inflammations,  if  the  invasion  be  sudden 
and  spontaneous,  without  previous  change  of  residence,  or  power- 
ful moral  impression ;  if  both  the  country  and  season  be  remarka- 
ble for  the  frequent  occurrence  of  pneumonia,  the  physician  should 
be  on  his  guard  against  the  previously  mentioned  gastric  and  cere- 
bral disorders,  and  while  he  delays  giving  a  decided  opinion,  should 
suspect  and  even  announce  the  possibility  of  commencing  pneu- 

*  The  diseases  spoken  of  as  "  masked  fevers  "  (filvres  larvees)  are,  properly, 
irregular  intermittents,  styled  by  Dr.  Copland  "simulating-  intermittents."  (Med. 
Diet.  art.  Int.  Fever. )  He  states  their  assumption  of  very  diversified  forms  ;  or 
rather,  that  various  affections,  and  chiefly  those  of  the  nervous  system,  may  assume 
an  intermittent  form.  The  rheumatic  and  neuralgic  forms  are  the  most  common. 
The  type  of  **  masked  ague  "  is  generally  quotidian,  double  tertian  or  tertian  ; 
sometimes  quartan,  or  double  quartan.  The  disease  is  most  common  in  spring 
and  autumn,  especially  the  former,  and  during  the  prevalence  of  easterly  winds  ; 
it  is  usually  attended  by  more  or  less  disorder  of  the  digestive,  biliary  and  excret- 
ing organs,  and  its  successful  treatment  depends  mainly  upon  attention  to  this 
circumstance.  —  (Op.  Cit.  p.  1088.  Am.  Ed.)  "The  intermittents  that  occur  in 
the  United  States,  are  chiefly  of  the  simple  form,  although  in  some  districts  they 
often  assume  one  or  more  of  the  complications  above  pointed  out,  when  they  are 
called  congestive  or  pernicious."  (Dr.  Lee.  Loc.  Cit.).  —  TRANS. 


322  DIAGNOSIS. 

monia.  But  in  this,  as  in  other  cases,  we  cannot  give  a  definite 
diagnosis,  except  at  the  period  when  the  local  and  characteristic 
signs  of  the  disease  are  distinctly  manifested,  and  this  is  not,  in 
most  instances,  until  the  second  or  third  day.  and  sometimes  still 
later.  In  typhoid  fever,  we  can  rarely  form  a  positive  diagnosis 
until  the  last  half  of  the  first  week.  In  chronic  diseases,  whose  in- 
vasion is  gradual,  several  weeks,  sometimes  many  months,  elapse, 
before  we  can  determine  their  nature,  seat,  and  other  essential  con- 
ditions. 

In  all  cases,  the  physician  should  be  on  his  guard  against  the 
desire  he  may  have  of  forming  an  opinion  upon  the  sort  of  disease 
which  is  about  to  commence,  and  also  against  the  very  natural 
impatience  of  the  patient's  friends.  The  danger  attending  a  pre- 
mature diagnosis  cannot  be  too  strongly  insisted  on  ;  not  only  4oes 
it  expose  us  to  error,  but,  moreover,  we  are  placed  in  such  a  con- 
dition, that  either  through  confidence  in  our  first  opinion,  or  fear  of 
appearing  undecided,  we  find  it  difficult  to  forsake  the  wrong  path 
upon  which  we  have  entered. 

It  is  not  alone  when  summoned  at  the  commencement  of  an 
acute  or  chronic  disease,  and  prior  to  the  development  of  those 
phenomena  which  characterize  it  at  a  later  period,  that  the  phy- 
sician meets  with  difficulties  and  finds  himself  obliged  to  delay 
giving  an  opinion.  In  the  opposite  cases,  that  is,  in  those  where 
an  acute  or  chronic  disease  is  about  to  terminate,  either  favorably 
or  unfavorably,  the  diagnosis  is  often  very  difficult.  The  transi- 
tion from  disease  to  convalescence  is  similar  in  a  great  number  of 
cases,  and  the  features  of  the  last  struggle  are  uniform  in  both 
acute  and  chronic  affections.  It  should  be  remembered  that  diag- 
nosis is  of  far  less  value  when  the  disease  approaches  its  termina- 
tion. There  are  cases,  however,  in  which  it  is  useful  to  know 
what  the  disease  is  which  has  proved  fatal  to  the  patient :  not  to 
mention  facts  appertaining  to  legal  medicine,  it  is  interesting  to 
know,  when  the  father  of  a  family  dies,  whether  the  disease  which 
proved  fatal  to  him  be  capable  of  hereditary  transmission  ;  and  if, 
contrary  to  custom,  the  physician  was  not  summoned  until  the 
latter  hours  of  the  patient's  life,  and  the  information  he  acquires,  to- 
gether with  the  examination  of  the  actual  symptoms,  be  insufficient 
to  decide  his  opinion,  the  extreme  weakness  of  the  patient  forbid- 
ding the  methodical  examination  of  the  different  organs,  examina- 
tion after  death  can  alone  furnish  the  desired  solution.  When  a  dis- 
ease terminates  favorably,  its  exact  diagnosis  is  generally  of  but 
little  consequence.  There  are,  however,  exceptions  ;  thus,  when  a 
patient  is  near  the  termination  of  an  eruptive  fever,  it  is  of  some 
importance  to  know  whether  it  has  been  scarlatina  or  rubeola ;  not 
only  because  the  first  requires  more  strict  and  prolonged  precau- 
tions during  convalescence,  on  acccount  of  the  anasarca  which 
may  supervene,  but  also  because  in  after  life,  the  individual  who 
knows  with  which  of  these  diseases  he  has  been  affected,  will 
avoid  the  double  inconvenience  of  either  taking  superfluous  pro- 
phylactic precautions,  or  of  neglecting  those  which  are  necessary. 


DIAGNOSIS.  323 

The  manner  in  which  desquamation  takes  place,  furnishes,  in 
this  case,  an  unequivocal  diagnostic  sign :  it  comes  on  more 
quickly,  and  the  scales  are  small  after  rubeola ;  it  is  slower  after 
scarlatina,  the  epidermis  is  smooth  and  shining,  the  fingers  look  as 
though  covered  with  dried  serous  membrane  [peau  de  baudruche, 
q.  v.]  the  epidermis  comes  off  in  long  strips,  and  sometimes  even 
in  the  form  of  gloves. 

When  a  disease,  not  yet  in  its  last  stage,  has  already  gone 
through  the  greater  part  of  its  course,  the  diagnosis  may  also  pre- 
sent certain  difficulties  to  the  physician  who  is  then  called  for  the 
first  time,  and  for  the  reason  that  he  has  not  witnessed  the  primary 
evolution  of  the  antecedent  phenomena.  From  this  arises  the  in- 
dispensable necessity  of  ascertaining  as  accurately  as  possible, 
from  the  patient  and  those  about  him,  and  especially  from  the 
physician  previously  in  attendance,  the  series  of  phenomena  succes- 
sively observed,  from  the  invasion  of  the  disease  to  the  time  of 
examination.  Failure  to  obtain  a  part  of  this  information  might 
sometimes  render  it  impossible  for  the  physician  to  give  a  precise 
opinion  in  regard  to  the  case  in  question. 

2.  Difficult  Diagnosis  arising  from  the  Predominance  of  the 
general  or  sympathetic  Phenomena,  or  from  the  obscurity  or  ab- 
sence of  local  Phenomena.  —  When  an  important  organ  is  the  seat 
of  serious  lesion,  sympathetic  phenomena  are  manifested  by  the 
others,  and  particularly  by  the  heart  and  brain,  which,  of  all  the 
viscera,  are  those  most  actively  associated  with  the  others  when 
diseased ;  the  digestive  and  respiratory  organs  are  by  no  means 
strangers  to  these  sympathetic  influences.  In  many  cases,  and  in 
acute  inflammations  particularly,  this  sympathy  extends,  simuU 
taneously,  but  in  different  degrees,  to  all  the  functions  of  the 
economy,  as  is  observed  in  the  various  forms  of  febrile  action,  to 
which  an  entire  article  will  be  devoted. 

When  the  general  and  sympathetic  phenomena  are  only  of  me- 
dium intensity,  they  do  not  mask  the  local  symptoms,  and  their 
presence  constitutes  no  obstacle  to  diagnosis,  but  it  is  otherwise  in 
those  cases  where  they  become  predominant ;  they  then  demand, 
and  sometimes  even  absorb,  the  observer's  attention,  who.  if  he  be 
not  aware  of  the  errors  to  which  this  unusual  intensity  of  sympa- 
thetic phenomena  may  give  rise,  would  be  exposed  to  frequent  de- 
ception in  his  diagnosis.  This  point  seems  to  us  so  important,  that 
we  think  it  requisite,  in  this  place,  to  glance  at  the  principal  sym- 
pathetic phenomena,  and  point  out  their  value. 

It  should  be  noticed,  in  the  first  place,  that  the  two  organs  which 
are  the  most  common  seat  of  sympathetic  phenomena,  are  far  less 
frequently  the  actual  seat  of  disease,  than  the  other  important 
viscera.  Thus  the  functional  disorders  of  the  brain  and  heart,  as 
cephalalgia,  delirium  arid  even  convulsions,  accelerated  circulation, 
palpitations  and  syncope,  in  the  great  majority  of  cases,  especially 
in  acute  affections,  have  their  source  in  other  organs ;  while  the 
serious  disorders  supervening  in  the  digestive  and  respiratory  or- 
gans belong,  most  frequently,  to  certain  diseases  of  these  organs 


324  DIAGNOSIS. 

themselves,  or  of  the  parts  which  assist  them  in  the  performance 
of  the  same  functions.  When  therefore  we  visit  a  patient  with 
delirium,  convulsions,  or  severe  headache,  we  are  induced  to  seek 
for  its  cause  in  the  remoter  organs  rather  than  in  the  brain  ;  as  also 
we  look  for  the  source  of  severe  fever  in  almost  any  other  organ 
than  the  heart. 

Cephalalgia  may  depend  upon  local  sanguineous  plethora,  in- 
flammation of  the  organs  contained  within  the  cranium,  tumors 
developed  in  the  same  parts,  or  softening  of  the  cerebral  pulp,  all 
which  diseases,  if  we  except  the  first,  are  rare  in  comparison  with 
those  which,  being  seated  elsewhere  than  in  the  brain,  produce 
sympathetic  cephalalgia.  Among  the  latter  we  shall  cite  only  the 
different  kinds  of  dyspepsia,  so  frequently  productive  of  those 
attacks  of  frontal  pain,  improperly  called  hemicrania  ;  acute  bron- 
chitis, in  which  the  cough  rings  so  painfully  through  the  head 
that  it  seems  ready  to  burst ;  prolonged  constipation,  typhoid  fever, 
eruptive  fevers  during  their  first  period,  the  paroxysms  of  inter- 
mittent fever,  and  almost  all  the  visceral  inflammations,  which,  in 
some  patients,  may  be  accompanied  by  more  or  less  intense  cephal- 
algia.* What  has  been  said  of  cephalalgia  is  equally  applicable  to 
delirium,  which  will  occur  twenty  times  perhaps  as  a  sympathetic, 
where  it  does  once  as  an  idiopathic  phenomenon,  that  is,  one  de- 
pendent upon  disease  of  the  brain  itself,  at  least  in  acute  affections. 
This  opinion  we  formerly  communicated  to  Dr.  Esquirol,  and 
asked  of  him,  as  the  most  competent  judge  in  such  cases,  if  the 
observations  that  he  had  been  enabled  to  make  upon  the  delirium 
of  the  insane,  had  led  him  to  similar  or  different  results.  He  replied 
that  he  was  convinced  that  in  the  insane,  as  well  as  in  those  affect- 
ed with  acute  disease,  delirium  is  most  frequently  sympathetic,  and 
consequently  subordinate  to  disease  of  some  other  organ  than  the 
brain.  Cephalalgia  and  delirium  have  no  very  precise  value  in  the 
diagnosis  of  cerebral  affections,  except  when  rigidity  or  paralysis  of 
one  part  of  the  body,  debility  or  loss  of  general  sensibility,  either 
of  one  or  several  senses,  are  added  to  one  or  both  of  these  two 
symptoms. 

What  has  been  said  of  delirium,  is  equally  applicable  to  convul- 
sions and  the  coma  which  succeeds  them  ;  those  observed  in  chil- 
dren in  the  first  period  of  eruptive  fevers,  and  during  dentition, 
those  occurring  in  puerperal  women,  those  noticed  in  hysteria,  in 
certain  forms  of  malignant  fever,  or  in  persons  under  the  influence 

*Some  instructive  remarks  upon  the  different  forms  and  causes  of  cephalalgia, 
are  quoted  from  Dr.  Wright's  Clinical  Lectures,  (published  in  the  Med  Times, 
Dec.  19,  1846,)  by  Dr.  Ranking  in  his  Half  Yearly  Abstract  of  the  Medical  Sci- 
ences, (January  to  July  1847,  p.  33,  art.  8.)  The  principal  varieties  mentioned, 
are  those  arising  from  the  habit  of  masturbation,  from  dyspepsia,  rheumatism  of 
the  cranial  integuments,  (an  affection  requiring  great  attention,  as  metastasis  to 
the  meninges  may  occur,)  syphilitic  taint  and  derangements  of  the  menstrual  func- 
tion. The  various  causes  which  give  rise  to  headache  show  the  correctness  of 
our  author's  rule  of  practice,  viz.  "to  seek  for  its  cause  in  remote  organs,  before 
referring  it  to  the  brain  ;  "  (p.  324).  Several  of  the  causes  of  sympathetic  head- 
ache, enumerated  by  Dr.  Wright,  are  not  noticed  by  Chomel.  —  TRANS. 


DIAGNOSIS.  325 

of  certain  poisons,  are  independent  of  any  cerebral  disease,  prop- 
erly so  called. 

Paralysis  of  motion  and  sensation  is,  of  all  cerebral  disorders, 
the  most  valuable  in  the  diagnosis  of  affections  of  the  brain  or  its 
appendages ;  hemiplegia  is  a  sign  almost  pathognomonic  of  some 
lesion  of  the  opposite  cerebral  hemisphere ;  paraplegia  generally 
reveals  the  existence  of  disease  of  the  spinal  marrow.  There  are, 
however,  sufficiently  numerous  examples  of  paralysis  of  the  lower 
limbs,  in  which,  on  post-mortem  examination,  no  lesion  whatever 
has  been  discovered ;  there  are  even  certain  cases  of  hemiplegia, 
in  which  the  brain,  examined  with  the  most  scrupulous  attention, 
has  exhibited  no  material  lesion.  We  have  also  seen  certain  indi- 
viduals in  whom  intestinal  disorder  has  for  some  hours  been  ac- 
companied by  torpor  of  the  entire  lateral  half  of  the  body,  which 
disappeared  completely  under  the  influence  of  abundant  alvine 
evacuations,  natural  or  artificial.  But  paralysis  is  no  less  the  most 
certain  sign  of  material  lesion  of  the  nervous  centres,  especially 
when  it  is  permanent,  and  very  pronounced,  and  occupies  either 
the  lateral  half,  or  the  lower  portions  of  the  body. 

Disturbance  of  the  cardiac  functions,  especially  in  acute  dis- 
eases, but  also  in  many  of  a  chronic  nature,  appertains,  in  the 
great  majority  of  cases,  to  the  sympathetic  phenomena.  When 
the  physician  discovers  in  the  patient  to  whom  he  is  called,  an  in- 
tense febrile  action,  the  idea  that  acute  inflammation  of  the  heart 
is  the  cause  of  the  acceleration  of  the  pulse  would  be  the  last 
which  would  occur  to  his  mind.  Syncope  itself  belongs  much 
more  frequently  to  certain  forms  of  abdominal  pain,  to  the  indis- 
position which  precedes  vomiting  and  alvine  evacuations,  to  certain 
moral  affections,  to  some  varieties  of  intermittent  fever,  or  to  the 
invasion  of  certain  acute  diseases,  than  to  diseases  of  the  heart 
and  its  envelopes.  Irregularity  in  the  pulsations  of  the  heart, 
which  seems  to  belong  more  particularly  to  material  lesion  of  this 
organ,  and  which,  in  reality,  constitutes  one  of  its  most  important 
signs  when  permanent,  (when,  for  example,  they  persist  for  one 
or  more  weeks,  and  more  particularly  when  they  last  for  many 
months,)  is  sometimes  transient,  like  the  sympathetic  phenomena, 
in  the  same  conditions  which  cause  syncope  ;  and  in  certain  cases, 
even  for  a  considerable  time,  when  the  same  causes  are  in  continu- 
al action,  as  in  the  case  reported  by  Morgagni,  arid  previously  cited, 
(p.  175.)  Excessive  sanguineous  evacuations  effect  changes  in  the 
force,  frequency,  and  rhythm  of  the  pulse,  and  even  in  the  sounds 
perceived  by  auscultation  (p.  167),  which  might  simulate  the 
existence  of  cardiac  lesions,  if  the  signs  furnished  by  percussion 
and  the  examination  of  the  different  circumstances  of  the  disease 
did  not  aid  us  in  the  diagnosis. 

Haemorrhage  and  dropsy  belong  to  the  secondary  phenomena 
furnished  by  disorder  of  the  circulatory  organs.  Both  appear,  in 
certain  circumstances,  with  great  intensity ;  they  predominate  so 
much  over  the  other  symptoms,  which  are  frequently  very  ob- 
scure, that  they  seem  to  constitute  the  entire  disease,  and  in  many 
28 


326  DIAGNOSIS. 

instances  it  is  really  very  difficult,  sometimes  even  impossible, 
for  a  considerable  period,  to  determine  accurately  whether  the 
hgemorrhage  or  the  dropsy  we  observe,  be  essential  or  symp- 
tomatic. 

Haemorrhage  occurring  during  the  course  of  diseases  *  is,  as  we 
have  elsewhere  seen,  general  or  partial  (p.  201).  The  former  is  of 
easy  diagnosis ;  it  furnishes  an  additional  sign  in  scorbutus  and 
pestilential  diseases,  and  renders  the  disease  more  manifest.  It  is 
chiefly  when  hsemorrhage  takes  place  from  a  single  organ,  that 
the  diagnosis  is  obscure.  Two  conditions  here  present  themselves ; 
in  the  first,  the  organ  which  is  the  seat  of  the  haemorrhage  has 
previously  shown  indubitable  signs  of  being  in  a  morbid  condition, 
and  in  that  case,  the  occurrence  of  haemorrhage  assists,  rather 
than  hinders,  diagnosis.  This  is  observed  in  individuals,  who, 
with  equivocal  signs  of  pulmonary  tubercle,  cancer  of  the  stomach, 
or  typhoid  fever,  suddenly  discharge  blood,  either  from  the  bron- 
chia, the  stomach,  nares  or  intestines :  in  these  cases,  the  haemor- 
rhage evidently  confirms  the  diagnosis.  In  the  second  condition, 
the  haemorrhage  appears  in  those  apparently  in  health,  manifesting 
itself  as  a  primary  and  unique  phenomenon ;  the  patient  and  those 
habitually  with  him,  assert  that  no  functional  alteration,  nor 
change  in  his  usual  appearance  preceded  the  haemorrhage,  and  the 
examination  of  the  cavity  whence  the  blood  is  discharged,  although 
often  repeated,  and  by  all  the  known  modes  of  exploration,  reveals 
no  lesion.  In  such  a  case  the  physician  remains  in  great  doubt ; 
the  extreme  rarity  of  essential  haemorrhage  should  lead  him  to 
fear  that  that  which  he  observes  is  symptomatic,  still  the  absence 
of  the  peculiar  characteristic  signs  of  material  lesion  does  not  allow 
him  to  affirm  its  existence ;  he  must,  then,  defer  giving  his  opinion 
until  new  signs  come  to  his  assistance.  Recovery  after  profuse 
haemorrhage  is  often  very  uncertain,  and  we  cannot  be  entirely 
confident  of  it  for  many  months  or  even  years.  This  is  particu- 
larly applicable  to  haemoptysis,  which  is  often  indicative  of  latent 
tubercle,  and  to  hasmatemesis  and  haematuria,  which  are  sometimes 
the  first  signs  of  lesion  in  the  stomach  or  urinary  organs.  Uterine 
haemorrhage  is  generally  more  easily  distinguished,  because  the  ex- 
ploration of  the  uterus  is  far  more  direct  and  complete  than  that  of 
the  lungs,  stomach,  and  kidneys  can  be  :  but,  on  the  other  hand, 
those  affections  to  which  this  kind  of  haemorrhage  appertains,  are 
more  varied  and  their  distinction  frequently  obscure.  Although 
the  uterus  is  the  seat,  during  several  years  of  life,  of  a  normal  san- 
guineous discharge,  and  essential  haemorrhage  is  more  rare  from 
this  organ,  than  from  the  others  which  have  just  been  named, 
considerable  uterine  haemorrhage  is,  notwithstanding,  in  a  great 
majority  of  cases,  a  symptomatic  phenomenon,  and  whenever  the 

*  Hsemorrhage  belongs,  at  one  time,  to  general  phenomena,  at  another,  to  the 
local  symptoms  of  diseases  :  the  first  alone  should  have  here  been  considered,  but 
we  thought  it  useful  to  add  a  few  words  upon  the  latter,  in  their  relation  to  diagno- 
sis ;  an  entire  article  seemed  unnecessary. 


DIAGNOSIS.  327 

physician  meets  with  a  case  of  this  nature,  either  in  the  old  or 
young,  married  or  single,  his  first  reflection  should  be  that  the 
existing  haemorrhage  arises  from  disturbed  pregnancy,  threatened 
abortion,  the  presence  of  some  foreign  body  in  the  uterus,  a  can- 
cerous affection,  granular  inflammation  or  some  other  less  frequent 
disease  of  this  organ. 

We  cannot  conclude  this  article,  devoted  to  the  semeiological 
value  of  haemorrhage,  without  reminding  the  reader,  that  that 
succeeding  the  suppression  of  the  menstrual,  or  of  some  other 
constitutional  or  periodical  sanguineous  discharge,  has  the  least 
importance  in  regard  to  prognosis,  and  is  most  frequently  uncon- 
nected with  material  lesion  of  the  parts  where  it  is  manifested. 

Finally,  it  should  be  remembered  that  the  suspension  of  consti- 
tutional haemorrhage,  particularly  of  the  menses,  unless  occurring 
with  the  natural  conditions,  is  almost  always  the  effect  of  disease, 
either  latent  or  manifest,  developed  sometimes  in  the  uterus,  but 
more  frequently  in  a  distant  organ,  as  the  stomach,  and  particu- 
larly the  lungs,  or  even  affecting  the  entire  system. 

We  class  dropsy  among  the  disorders  of  the  organs  of  circula- 
tion, because,  in  a  very  great  majority  of  cases,  it  arises  from  an 
obstruction  in  the  course  of  the  blood,  either  in  the  heart,  in  which 
case  dropsy  progressively  pervades  the  whole  system,  commencing 
at  the  extremities ;  or  in  some  point  of  the  venous  system,  the 
effusion  being  then  confined  to  the  parts  from  which  the  branches 
of  the  compressed  or  obliterated  vein  arise.  General  dropsy,  which 
has  supervened  gradually,  is  one  of  the  most  certain  signs  of  or- 
ganic affection  of  the  heart,  or  of  a  more  or  less  serious  change  in 
the  composition  of  the  blood,  or,  finally,  of  that  disease  of  the 
kidney  described  by  Dr.  Bright,  of  which  the  presence  of  albumen 
in  the  urine  is  the  pathognomonic  sign.  General  dropsy,  mani- 
festing itself  rapidly  in  an  acute  disease,  becomes  a  valuable  sign 
in  the  frequently  obscure  diagnosis  of  pericarditis  and  endocarditis. 
In  1826,  we  pointed  out  the  importance  of  this  phenomenon  in  acute 
pericarditis,*  and  in  the  course  of  the  same  year,  at  the  Clinique 
of  the  Hotel  Dieu,  this  sign  led  us  to  suspect  endocarditis  in 
a  young  female,  which  proved  fatal.  Finally,  when  an  individual 
is  attacked  with  acute  anasarca,  we  should  always  ascertain  if  he 
have  not  been  recantly  affected  with  some  eruptive  disease  :  ana- 
sarca, indeed,  is  observed  quite  often  in  convalescents  from  scarla- 
tina, the  material  cause  of  the  effusion  not  being,  as  yet,  accurately 
determined. 

The  diagnostic  signs  furnished  by  partial  dropsy,  are  equally 
important.  When  confined  to  a  single  limb,  it  indicates  compres- 
sion or  obliteration  of  its  veins.  The  examination  of  the  infiltrated 
limb,  enables  us  sometimes  to  recognise  in  the  course  of  the  vein, 
near  the  trunk  of  the  body,  a  very  firm  cylinder,  formed  by  the 
inflamed  and  indurated  vessel.  But  in  the  greater  number  of  cases, 
this  partial  oedema  of  a  limb  results  from  compression  made  upon 

*  Diet,  de  Medecine,  En  21  vol.  Art.  Pericardite. 


328  DIAGNOSIS. 

the  principal  vein,  by  a  tumor  developed  either  in  one  of  the  iliac 
fossae,  or  within  the  thorax,  according  as  the  infiltration  occupies 
the  thigh  or  the  arm :  in  certain  cases,  this  infiltration  is  the  first 
and  even  the  only  sign  which  indicates  the  existence  of  the  tumor 
or  leads  us  to  suspect  it,  and  can  alone  enable  us  to  form  a  correct 
diagnosis.  When  dropsy  occupies  the  two  lower  limbs  simultane- 
ously, it  may  depend  upon  compression  of  the  vena  cava  abdomi- 
nalis ;  but  most  usually,  this  form  of  oedema  is  only  the  first 
degree  of  general  dropsy,  which  begins  at  the  most  depending 
parts,  where  the  difficulty  with  which  the  blood  rises  in  opposition 
to  the  laws  of  gravity,  concurs  with  the  lesion  of  the  heart,  or  the 
change  in  the  blood,  in  the  production  of  serous  infiltration.  It  is 
otherwise  in  very  rare  cases,  where  dropsical  effusion  occupies  the 
superior  half  of  the  body :  we  then  cannot  doubt  the  existence  of 
a  considerable  obstacle  to  the  circulation  of  the  blood  in  the  vena 
cava  superior.  A  case  of  this  nature  occurred  the  present  year  at 
the  Medical  Clinique  of  the  Hotel  Dieu.  A  man  was  admitted,  whose 
face,  neck,  upper  half  of  the  chest,  and  both  arms,  presented  enor- 
mous serous  distention  which  contrasted  singularly  with  the  exces- 
sive emaciation  of  the  inferior  three  fourths  of  the  body.  The 
necropsy  disclosed  a  cancerous  tumor,  developed  in  the  mediasti- 
num, by  which  the  vena  cava  superior  was,  as  it  were,  strangula- 
ted, confirming,  at  least  as  far  as  regarded  the  existence  of  a  tumor, 
the  diagnosis  which  had  been  made;  nothing  had  indicated  that 
this  tumor  was  necessarily  cancerous,  and  the  relative  frequency 
of  aneurismal  tumors  of  the  aorta  would  more  particularly  have 
aroused  suspicions  of  the  latter  cause  of  compression. 

Among  the  partial  dropsical  effusions,  we  shall  enumerate  ascites, 
the  most  important  diagnostic  sign  of  cirrhosis  of  the  liver  ;  *  also 
the  serous  infiltration  which  supervenes  in  prolonged  intermittent 
fevers,  arid  which  is  distinguished  by  the  dull  yellow  tinge  of  the 
skin  and  congestion  of  the  spleen,  which,  like  the  dropsy,  are  the 
consequence  of  these  fevers.  We  would  also  mention  the  serous 
infiltration  developed  in  the  vicinity  of  certain  deep-seated  abscess- 
es, and  which  is,  in  some  cases,  almost  their  only  sign ;  and  the 
serous  infiltration  of  one  half  of  the  face,  a  phenomenon  which 
alone,  in  certain  cases,  leads  us  to  seek  and  discover  an  abscess 
formed  near  the  alveolar  border  of  one  of  the  maxillae,  and  arising 
almost  always  from  a  carious  tooth. 

3.  The  secondary  or  sympathetic  phenomena  furnished  by  the 
digestive  and  respiratory  organs,  are,  as  we  have  remarked,  of  far 
less  importance,  and  rarely  embarrass  diagnosis.  The  anorexia 

*  In  ascites  dependent  on  lesion  of  the  liver,  the  urine  is  always  more  or  less 
deeply  colored,  whilst  in  renal  ascites  (Bright's  disease  or  otherwise),  it  is  white 
or  colorless  (Rayer).  This  characteristic  condition  of  the  urine  was  known  to 
the  Arabian  physicians.  —  (Monthly  Journal  of  Med  Science,  Dec.  1847,  quoted 
by  Dr.  Ranking,  Med.  Abst.  Jan.  to  July,  1847.)  Dr.  Budd  declares  the  urine 
in  cirrhosis  to  be  almost  always  scanty  and  high  colored,  depositing  lithate  of  am- 
monia. (Diseases  of  the  Liver.  Cirrhosis.)  This,  being  constant,  will  always 
assist  in  the  differential  diagnosis  of  ascites.  —  TRANS. 


DIAGNOSIS.  329 

accompanying  the  greater  number  of  diseases,  and  the  acceleration 
of  respiration  in  all  cases  where  the  circulation  is  quickened,  hardly 
ever  lead  the  physician  to  suppose  the  stomach  or  lungs  the  seat 
of  a  disease  which  might  be  situated  in  any  other  part  of  the  body. 
The  contrary  is  true  of  vomiting,  cough,  and  dyspnoea. 

Vomiting  does  not  always  depend  upon  disease  of  the  stom- 
ach; its  productive  cause  may  be  elsewhere  seated.  We  have 
previously  stated  the  numerous  and  various  conditions  which  may 
cause  vomiting,  and  lead  to  the  supposition  of  an  acute  or  chronic 
affection  of  the  stomach.  We  shall,  at  present,  only  call  to  mind 
the  difficulty  presented  by  certain  cases  of  misunderstood  or  sim- 
ulated pregnancy,  and  of  epiploic  or  intestinal  hernia,  so  small,  or 
so  far  concealed  by  obesity,  that  they  are  not  discovered  until  they 
have  been  suspected,  and  after  a  most  attentive  search.  The  ob- 
stinate vomiting,  which,  in  certain  instances,  is  the  predominant 
symptom  in  hepatic  and  nephritic  colic,  and  which  may  mask  the 
local  symptoms,  should  also  be  mentioned.  We  would  particularly 
mention  those  cases,  as  yet  too  little  known  by  most  physicians, 
of  accidental  occlusion  of  the  intestine,  of  which  vomiting  is  the 
most  apparent  sign ;  a  disease  confounded  with  the  peritonitis  con- 
sequent upon  it,  and  in  which  energetic  purgatives,  assisted  by  the 
external  and  internal  use  of  ice,  often  produce  most  wonderful 
effects. 

Cough  and  dyspnoea  are  two  phenomena  sometimes  determin- 
ed sympathetically  by  an  affection  of  remote  organs,  and  may 
render  diagnosis  difficult  or  erroneous.  We  have  previously  men- 
tioned the  principal  forms  of  sympathetic  cough  (p.  153),  we  need 
not  re-enumerate  them :  we  shall  only  remark  that  sympathetic 
cough  is  habitually  dry,  if  we  except  that  called  gastric,  which  is 
often  accompanied  by  a  glairy  exhalation  from  the  posterior  fauces. 
Sympathetic  cough,  also,  is  not  accompanied  with  those  ausculta- 
tory  and  percussory  phenomena  belonging  to  pulmonary  diseases, 
and  which  manifest  themselves  almost  constantly  with  idiopathic 
cough.  Dyspnoea  rarely  occurs  as  a  sympathetic  phenomenon ; 
it  belongs  almost  exclusively  to  affections  of  the  pulmonary  or 
circulatory  organs,  which  are  intimately  associated,  or  to  material 
lesions  of  the  nerves,  which  preside  over  respiration  and  circula- 
tion ;  in  all  these  cases,  it  is  idiopathic,  or  may  be  so  considered. 
That  form  of  dyspnoea  observed  in  cases  of  enormous  distention 
of  the  abdomen  in  ascites,  tympanitis,  and  encysted  dropsy,  is 
entirely  mechanical,  and  its  source  cannot  escape  the  most  unprac- 
tised eye. 

Sympathetic  dyspnoea  is  hardly  ever  observed,  except  under 
the  influence  of  certain  moral  affections,  whose  effects  extend,  in 
some  persons,  to  the  entire  nervous  system,  as  in  females  affected 
with  so  called  hysteria,  while  in  others  they  are  concentrated  in 
the  respiratory  organs.  Certain  stomachal  affections,  character- 
ized by  an  acute  pain  or  a  kind  of  spasm  in  the  epigastric  region, 
sometimes  occasion  dyspnoea  so  intense,  that  the  patient  appre- 
hends suffocation.  In  all  these  cases,  the  cause  of  the  dyspnoea, 
28* 


330  DIAGNOSIS. 

the  diagnostic  signs  and  remedial  indications,  are  to  be  sought 
elsewhere  than  in  the  respiratory  organs  or  their  appendages. 

Having  reviewed  the  sympathetic  phenomena  which  may  be 
presented  by  each  of  the  four  great  functions,  and  pointed  out  the 
difficulties  of  diagnosis  resulting  from  the  intensity  of  these  phe- 
nomena, we  shall  now  examine  febrile  action,  which  comprises  all 
functional  disorde^  when  considered  in  regard  to  the  obstacles  it 
places  in  the  way  of  the  diagnosis  of  disease,  on  the  one  hand, 
when  by  its  predominance  it  masks  the  local  symptoms,  or  when 
these  symptoms  are  entirely  wanting ;  on  the  other,  when  it  is  so 
slight  in  itself  as  to  remain  almost  unperceived :  for  we  should  not 
forget  that  if  the  violence  of  the  fever  be  a  frequent  obstacle  to 
diagnosis,  its  presence  is  sometimes  one  of  its  necessary  elements. 

Febrile  action  is  observed  with  either  the  intermittent  or  continu- 
ed type,  and  with  an  acute  or  chronic  form.  It  is  particularly  in1 
these  two  points  of  view  that  it  should  be  examined,  when  the 
diagnosis  is  difficult.  The  degree  of  intensity  and  the  inflamma- 
tory, adynamic  or  ataxic  forms  of  fever  have,  in  this  connection, 
only  a  secondary  interest. 

Febrile  action  which  manifests  itself  with  the  intermittent  type, 
is  generally  considered  as  exclusively  appertaining  to  essential  in- 
termittent fevers,  and  as  requiring  to  be  treated,  in  consequence  of 
this  opinion,  by  the  specific  remedy  usually  employed  in  these  dis- 
eases. This  opinion,  which  is  mainly  true  in  regard  to  those 
febrile  affections  whose  paroxysms  are  widely  separated,  as  in  the 
quartan  and  even  the  tertian  type,  is  no  longer  so,  when  we  arrive 
at  the  quotidian,  and  more  especially  the  double  quotidian.  Pro- 
portionally, indeed,  to  the  proximity  of  the  paroxysms,  the  num- 
ber of  cases  in  which  the  fever  is  symptomatic  becomes  greater, 
so  that,  by  referring  to  the  results  of  our  own  observation,  which 
extends  over  a  space  of  more  than  thirty  years  constantly  passed 
in  the  hospitals,  the  double  quotidian  fever  is  always  symptomatic  ; 
the  quotidian  is  so  in  more  than  half  the  cases  ;  the  tertian  rarely ; 
the  quartan  never.  We  consider  this  result  as  more  important, 
from  the  fact  that  many  physicians,  otherwise  well  informed,  are 
not  sufficiently  aware  of  the  frequency  of  symptomatic  intermit- 
tent fevers,  and  how  necessary  it  is  to  guard  against  the  too  gen- 
eral tendency  to  declare  the  existence  of  essential  intermittent 
fevers  wherever  the  intermittent  type  is  perceived.  Here,  as  we 
have  seen,  the  duration  of  the  intermission  is  highly  important, 
since  the  farthest  removed  paroxysms  belong  constantly  to  essen- 
tial iritermittents,  which  are  the  nearest  allied  to  the  symptomatic 
fevers.  It  is,  then,  in  the  intermediate  types  that  difficulties  may 
occur  in  diagnosis ;  to  these,  consequently,  our  attention  should  be 
chiefly  directed. 

The  tertian  type,  whose  paroxysms  occur  generally  at  intervals 
of  about  thirty-six  hours,  does  not,  as  we  have  said,  belong,  except 
very  rarely  and  as  if  accidentally,  to  symptomatic  fevers.  \V  e 
have  had,  in  the  clinical  wards  of  the  Hotel  Dieu,  an  individual  af- 
fected with  gastro-enteritis  of  medium  severity,  with  tertian  febrile 


DIAGNOSIS.  331 

paroxysms,  evidently  under  the  control  of  the  regimen  adopted  by 
the  patient.  In  fact,  during  the  eight  or  ten  days  which  preceded 
his  admission,  this  man  had  alternately  tried,  on  the  one  day,  food 
whose  ingestion  was  followed  by  a  febrile  paroxysm,  and  on  the 
following  day,  abstinence;  simple  abstinence  from  food  prevented 
the  return  of  these  paroxysms,  which  may  be  termed  artificial, 
and  the  use  of  certain  antiphlogistic  remedies  subdued  the  gastro- 
intestinal inflammation  in  a  short  time.  Evidently,  in  this  case, 
the  febrile  paroxysms  were  the  result  of  inflammation  of  the  diges- 
tive passages,  exasperated  every  two  days  by  the  unseasonable  use 
of  food.  The  repeated  action  of  cold  may  produce  effects  in 
bronchitis,  analogous  to  those  determined  by  food  in  gastritis,  and 
accidentally  give  to  the  disease  the  appearance  of  tertian  intermit- 
tent fever ;  but  these  cases  are  very  rare,  and  the  tertian  type  must 
be  regarded  as  appertaining  to  essential  intermittent  fevers. 

It  is  otherwise  with  the  quotidian  type,  as  we  have  previously 
remarked;  the  greater  number  of  diseases  presenting  this  type, 
and  perhaps  all  those  of  the  double  tertian,  belong  to  symptomatic 
fevers.  When,  therefore,  a  disease  manifests  itself  with  the  quo- 
tidian type,  our  whole  attention,  in  examining  the  case,  should  be 
given  to  the  determination  of  the  essential  or  the  symptomatic 
nature  of  the  fever.  In  the  solution  of  this  question,  which  is  so 
often  presented  in  the  practice  of  medicine,  it  is  interesting  to  know 
the  affections  in  which  the  symptomatic  quotidian  type  has  been 
particularly  observed.  There  is,  perhaps,  no  inflammation,  acute 
or  chronic,  no  suppuration,  either  manifest  or  concealed,  which 
has  not  been  accompanied  during  a  certain  part  of  its  course,  by 
quotidian  paroxysms.  But  it  is  chiefly  in  inflammations  of  the 
bronchial,  digestive,  and  urinary  mucous  membranes,  in  the  sec- 
ond stage  of  tuberculous  affections,  and  in  cases  of  deep-seated  or 
superficial  ulceration,  that  this  febrile  type  occurs.  Thus,  when 
we  are  observing  a  quotidian  intermittent,  we  should  endeavor  to 
ascertain,  by  the  examination  of  the  patient,  whether  the  parox- 
ysms do  not  depend  upon  some  one  of  these  affections.  In  many- 
cases  the  diagnosis  is  easy  :  on  one  hand,  the  primary  disease  mani- 
fests itself  by  signs  peculiarly  its  own  ;  on  the  other,  the  febrile 
paroxysms,  instead  of  commencing  in  the  morning  or  at  mid-day, 
at  precise  hours,  or  at  least  with  uniform  intervals  of  twenty-two, 
or  twenty-six  hours,  for  instance,  begin  almost  constantly  towards 
evening,  that  is,  at  the  time  when  the  paroxysms  of  the  phlegma- 
siae,  and  of  almost  all  diseases  of  continued  type,  occur.  But 
there  is  not  always  this  distinctness.  In  certain  cases,  the  local 
symptoms  of  the  inflammation,  the  abscess,  or  the  tuberculous 
affection,  are  obscure,  easily  escaping  the  notice  of  the  physician 
who  does  not  search  for  them ;  sometimes  even,  they  are  not  evi- 
dent to  the  one  who  suspects  them,  and  who  employs  all  the  known 
explorative  means  for  their  discovery  ;  in  certain  cases,  finally,  the 
febrile  paroxysms  become  so  intense,  that  they  might  be  considered 
as  pertaining  to  the  pernicious  form  of  intermittent  fever,  and  this 
disproportion  between  the  general  phenomena  and  the  local  lesion 


332  DIAGNOSIS. 

renders  the  diagnosis  very  difficult,  sometimes  even  impossible, 
until  new  signs  come  to  our  assistance.  These  paroxysms  of  a 
pernicious  nature  are  especially  observed  in  diseases  of  the  urinary 
passages,  and  in  ruptures  of  the  canals  and  reservoirs  of  this  fluid ; 
and  their  origin  is  unknown  until  the  moment  when  gangrenous 
inflammation  of  the  tissues  infiltrated  with  urine,  reveals  the  cause 
of  all  the  disorder.  Generally,  also,  in  these  very  rare  cases,  the 
febrile  action  assumes  rather  the  remittent  than  the  intermittent 
type  :  by  carefully  questioning  the  patient  and  the  assistants,  we 
sometimes  succeed  in  learning  tfyat  previously  to  the  existing 
affection,  there  was  some  disorder  in  the  urinary  passages,  that  the 
first  chills  came  on  after  violent  efforts  to  pass  urine,  etc.  But  the 
following  important  fact,  above  all  others,  may  enlighten  the  phy- 
sician in  the  midst  of  the  difficulties  with  which  the  severity  of  the 
paroxysms  surrounds  the  diagnosis,  viz.  that  in  a  healthy  coun- 
try (at  Paris  for  instance),  nothing  is  more  rare  than  essential 
pernicious  fever,  therefore,  unless  it  has  been  elsewhere  con- 
tracted, we  must  suspect  a  symptomatic  fever  in  the  paroxysms 
which  are  observed  of  this  pernicious  nature,  and,  by  an 
attentive  and  methodical  exploration  of  all  the  organs  and  func- 
tions, endeavor  to  discover  the  source  of  those  alarming  symp- 
toms, which  are,  in  reality,  but  the  shadow  of  the  disease. 

Lastly,  it  frequently  happens  that  the  paroxysms  of  certain  acute 
affections,  particularly  those  of  typhoid  fever,  are  distinguished,  for 
several  consecutive  days,  by  chills,  which  may  occur  at  the  same 
hour,  and  give  to  the  disease  the  appearance  of  the  intermittent,  or 
remittent  type ;  but  this  is  only  the  exceptional  course,  and  after 
some  days  the  disease  resumes  the  continued  type  peculiar  to  itself. 
The  same  thing  occurs,  either  in  the  first  period  of  certain  acute 
inflammations,  in  which  every  exacerbation  of  the  disease  may  be 
marked,  as  was  its  invasion,  by  successive  chills ;  or  in  an  ad- 
vanced stage  of  certain  acute  diseases,  when  metastatic  abscess  is 
formed.  In  these  various  conditions  we  observe  the  great  impor- 
tance of  quotidian  chills,  in  a  diagnostic  point  of  view. 

Before  concluding  our  remarks  upon  the  diagnosis  of  intermit- 
tent affections,  we  would  add,  that,  if  in  many  cases  the  predomi- 
nance of  the  febrile  action  masks  the  original  disease,  in  some 
cases  of  essential  intermittent  fever,  on  the  contrary,  the  paroxysms 
are  so  feebly  marked,  that  they  easily  escape  the  superficial  ob- 
server, who  would  see  only,  in  the  patient  he  attends,  a  want  of 
power  in  the  digestive  organs,  oedema  of  the  lower  limbs,  and  en- 
largement of  the  spleen.  It  is  particularly  in  those  places  where 
essential  intermittent  fevers  prevail,  and  in  those  individuals  who 
have  exhibited  their  manifest  access,  that  the  obscure  paroxysms, 
we  have  thought  it  important  to  notice,  are  observed. 

Continued  febrile  action  may  be  either  acute  or  chronic  ;  in  the 
latter  form,  it  is  called  hectic  fever  ;  in  the  former,  it  is  divided 
into  ephemeral  and  synochal,  according  as  it  only  attains  or  con- 
tinues beyond  the  third  day.  These  are  not  useless  distinctions, 
when  continued  febrile  action  is  considered  in  regard  to  diagnosis. 


DIAGNOSIS.  333 

Ephemeral  fever  is  often  the  symptom  of  slight  inflammation,  as 
coryza,  or  cynanche  tonsillaris,  whose  symptoms  are  sometimes 
prolonged,  with  diminishing  intensity,  after  the  cessation  of  the 
febrile  action.  But  often,  likewise,  ephemeral  fever,  particularly 
in  children,  is  a  primary  or  essential  disease;  in  some  individuals 
it  results  from  certain  causes  which  reproduce  it  whenever  they 
are  in  action ;  unusual  exercise,  exposure  to  cold  or  heat,  strong 
emotion,  or  errors  in  diet,  are  sometimes  sufficient  to  determine  a 
very  intense  febrile  action  accompanied  by  alarming  symptoms, 
but  ceasing  after  twenty-four  or  forty-eight  hours,  without  any 
remedial  aid. 

When  a  disease  commences  with  continued  febrile  action,  it  is 
generally  difficult  and  often  impossible  to  determine  its  duration, 
whether  it  will  remain  within  or  go  beyond  the  limits  of  ephemeral 
fever.  This  uncertainty  exists,  indeed,  at  the  commencement  of 
many  acute  affections,  whose  diagnosis,  as  we  have  said,  cannot 
be  pronounced  until  the  second  or  third  day.  Most  frequently,  it 
is  not  until  after  the  cessation  of  ephemeral  fever,  that  the  diag- 
nosis is  entirely  clear.  The  uncertainty  is  not  of  long  duration, 
and  not  seriously  injurious.  But  when  the  continued  febrile  action 
exceeds  the  period  of  ephemeral  fever,  and  especially,  when  it  con- 
tinues beyond  the  fifth  or  the  sixth  day,  and  there  are  no  manifest 
signs  of  a  local  affection,  the  diagnosis  may  be  very  difficult,  and 
the  uncertainty,  a  serious  inconvenience.  The  principal  affections 
with  which  it  is  connected  are  latent  visceral  inflammations,  and 
eruptive  affections  of  abnormal  course,  inflammation  of  the  veins 
or  lymphatics,  and  typhoid  fever. 

There  are  but  few  visceral  inflammations  sufficiently  grave  to 
produce  febrile  action  persisting  with  considerable  intensity  until 
the  fifth  day,  without  its  existence  being  revealed  by  local  signs. 
There  have  been  cases,  however,  where  inflammation  of  the  uterus 
and  its  appendages,  or  of  some  portion  of  the  peritoneum  or  neigh- 
boring cellular  tissue,  especially  after  parturition,  has  occasioned 
febrile  action,  whose  source  it  is  difficult  to  determine,  although  the 
patient's  peculiar  state  calls  attention  particularly  to  the  affected 
point.  An  attentive  exploration  of  the  uterus  and  pelvic  cavity, 
by  vaginal  and  rectal  examination,  and  by  palpation  of  the  abdo- 
men, does  not  always  enable  us  to  establish  an  immediate  diag- 
nosis, and  in  some  cases  many  weeks  elapse  before  the  characteristic 
signs  begin  to  appear.  With  the  exception  of  these  particular 
cases,  the  chest  is  the  most  frequent  seat  of  those  latent  inflamma- 
tions, which  febrile  action  leads  us  to  suspect,  although  not  de- 
clared by  any  local  symptom.  Not  to  mention  certain  cases  of 
pericarditis  without  effusion,  of  interlobular  pleurisy,  or  that  con- 
fined to  the  diaphragmatic  and  mediastinal  regions,  where  auscul- 
tation and  percussion  would  be  almost  unavailable,  we  would  par- 
ticularly notice  that  deep-seated  pneumonia,  equally  inaccessible 
to  our  means  of  exploration,  and  which,  sometimes  occurring  with- 
out pain  in  the  side  or  sputa,  almost  defies  discovery.  In  these 
obscure  cases,  however,  the  intensity  of  the  invading  chill,  whose 


334  DIAGNOSIS. 

value  we  have  already  mentioned,  the  persistence  of  febrile  action 
for  a  longer  period  than  four  or  five  days,  particularly  in  a  patient 
beyond  the  age  exposed  to  typhoidal  affections,  and  in  a  season 
when  pneumonia  is  prevalent,  should  suffice,  not  wholly  to  con- 
vince the  physician,  but  to  lead  him  to  a  confident  presumption, 
that  the  febrile  action  observed  arises  from  pneumonia. 

In  the  eruptive  affections,  the  febrile  action  usually  precedes  the 
exanthema  by  a  few  days  only  ;  it  is,  then,  in  entirely  exceptional 
cases,  that  the  fever  of  invasion  persists  until  the  fourth  or  fifth 
day,  before  the  appearance  of  the  eruption  ;  and  it  is  even  more 
unusual  that  the  contagious  principle  of  variola,  rubeola,  or  scar- 
latina, causes  a  febrile  action,  which  is  not  followed  by  an  erup- 
tion, (variola  sine  variolis,  morbilli  sine  morbillis,  scarlatina  sine 
scarlatina.)  In  cases  where  the  fever  persists,  and  no  eruption 
appears,  the  diagnosis  may  be  elucidated  to  a  certain  extent,  by 
considering  the  prevailing  diseases,  by  the  symptoms  peculiar  to 
the  period  of  invasion  of  each  of  the  eruptive  fevers,  as  the  coryza, 
epiphora  and  cough  in  rubeola,  the  sore  throat  in  scarlatina,  and 
the  lumbar  pain  in  variola ;  and  in  each  of  them  by  the  appear- 
ance of  an  eruption  upon  the  mucous  membrane  of  the  mouth, 
similar  to  that  which  should  have  been  manifested  upon  the  skin, 
and,  finally,  by  the  inaptitude  to  contract  the  same  disease  in  future. 

Inflammation  of  the  veins  or  lymphatics  causes  intense  and 
permanent  febrile  action,  whose  source  is  sometimes  very  obscure. 
A  slight  wound,  the  contact  of  putnfied  matter  with  a  simple  ex- 
coriation, sometimes  a  mere  contusion  upon  the  surface  of  the 
body  in  a  part  where  the  veins  rest  upon  a  bone,  as  the  cranium 
and  the  front  of  the  tibia,  have  been  the  occasion  of  latent  phle- 
bitis, the  sole  symptom  of  which  has  been  intense  fever  for  a 
period  of  from  eight  to  ten  days,  until  the  appearance  of  multiple 
abscess  beneath  the  skin  established  the  diagnosis.  In  these  dif- 
ficult cases,  the  necessity  of  tracing  the  febrile  action  to  its  cause, 
should  lead  the  physician  to  put  his  questions  with  a  view  to  all 
those  circumstances  likely  to  induce  phlebitis ;  and  when  this  in- 
quest has  given  the  proper  direction  to  our  search,  the  attentive 
examination  of  the  region  where  the  disease  commenced  some- 
times reveals  modifications  in  the  consistence,  volume,  and  sensi- 
bility of  its  vessels,  which,  although  slight,  become  very  valuable 
diagnostic  signs. 

But  of  all  the  affections  where  continued  and  prolonged  febrile 
action  is  observed,  without  local  phenomena  clearly  indicative  of 
its  source,  typhoid  fever  is  indisputably  the  most  common.  The 
greater  part  of  those  affections  described  by  writers  of  former  ages 
under  the  name  of  essential  fevers  are,  evidently,  as  we  have 
proved,*  only  various  forms  of  typhoidal  disease,  since  post-mor- 
tem examination  reveals  identical  lesions  in  all  these  fevers,  which 
are  not  met  with  in  any  other  disease.  From  this  fact  it  follows, 
that  typhoid  fever  is  one  of  the  most  frequent  affections  noticed  in 

*  Logons  de  Clinique  Medicale  sur  la  Maladie  Typhoi'de. 


DIAGNOSIS.  335 

our  climate,  and  if  we  consider  that  the  general  symptoms  which 
accompany  it  are  often  very  grave,  while  the  local  phenomena 
connected  with  the  anatomical  changes  are  most  frequently  ob- 
scure, and  sometimes  almost  null,  we  shall,  by  a  comparison  of 
these  two  conditions,  have  the  natural  explanation  of  the  opinion 
often  expressed  in  our  clinical  instructions,  viz.  that  an  acute  fever 
persisting  beyond  the  eighth  day,  and  presenting,  up  to  that  period, 
after  methodical  and  repeated  explorations,  no  indication  of  local 
inflammation  sufficiently  intense  to  explain  the  fever,  should  be 
considered  typhoidal,  at  least  in  our  climate,  and  in  our  usual  san- 
itary condition.*  Certain  rare  exceptions  to  this  practical  axiom 
do  not  invalidate  it. 

Hectic  fever,  or  the  chronic  form  of  continued  febrile  action,  is 
also  of  great  importance  in  the  diagnosis  of  disease,  whether,  as  is 
quite  often  the  case,  the  hectic  fever  being  apparent,  the  lesion  which 
produces  it  remains  concealed ;  or  whether  this  affection  is  itself 
obscure  and  uncertain  in  its  manifestation.  If  we  except  the  very 
rare  cases  where  it  is  the  direct  result,  either  of  a  profound  moral 
affection,  of  excesses  or  of  considerable  evacuations,  hectic  fever  is 
almost  always  the  effect,  and  consequently,  the  sign,  of  chronic  sup- 
puration, itself  arising  from  essential  or  symptomatic  inflammation; 
caries  of  the  bones,  for  instance,  or  the  tuberculous  affection.  In 
a  considerable  number  of  cases,  it  is  difficult  to  determine  to  which 
of  these  lesions  the  hectic  fever  should  be  ascribed  :  certain  forms 
of  chronic  abscess  are  unaccompanied  by  any  local  sign  whatever ; 
some  chronic  inflammations,  likewise,  occasion  only  a  progressive 
and  apparently  inexplicable  marasmus,  and  the  tuberculous  affec- 
tion, the  most  frequent  of  all  the  diseases  productive  of  hectic 
fever,  is  at  the  same  time  one  of  those  whose  local  symptoms  may 
longest  remain  obscure.  Thus  the  existence  of  hectic  fever,  with- 
out local  lesion  to  explain  it,  is  a  sign  almost  pathognomonic  of 
tubercular  disease,  as  an  acute  fever,  whose  source  is  not  evident 
after  seven  or  eight  days'  continuance,  is  almost  characteristic  of 
typhoidal  affection. 

Before  approaching  another  subject,  we  would  add  that  in  the 
continued,  as  well  as  in  the  intermittent,  type,  the  difficulties  of 
diagnosis  do  not  always  depend  upon  the  predominance  of  the 
febrile  action  and  the  obscurity  of  the  local  symptoms.  In  certain 
cases,  on  the  contrary,  the  local  symptoms  are  sufficiently  well 
marked,  but  the  slight  intensity  of  the  febrile  action  might  lead  us 
to  suppose  that  it  was  entirely  absent,  and  thus  communicate  an 
uncertainty  to  the  diagnosis  of  certain  affections  where  the  febrile 
condition  is  an  important  sign.  Thus,  individuals  are  met  with, 
aged  persons  particularly,  in  whom  the  examination  of  the  chest 
and  the  character  of  the  sputa  announce  the  existence  of  pneumo- 
nia ;  but  the  state  of  the  pulse,  the  slight  heat  of  the  skin,  especially 

*That  is  to  say,  abstraction  being  made  of  the  times  and  places  in  which  epi- 
demic or  pestilential  diseases  are  prevalent ;  such  as  contagious  typhus,  the  plague, 
yellow  fever,  certain  kinds  of  puerperal  fever,  etc. 


336  DIAGNOSIS. 

if  we  examine  the  patient  in  the  morning,  seem  to  indicate  an 
apyrectic  state  which  little  harmonizes  with  such  an  affection.  In 
such  cases,  by  ascertaining  the  state  of  the  healthy  pulse  in  these 
individuals,  by  examining  the  degree  of  heat  elsewhere  than  at 
the  wrist,  upon  parts  constantly  covered  by  the  bedclothes,  as  the 
chest  or  abdomen,  by  observation  of  the  patient  at  different  parts 
of  the  day,  we  are  enabled  to  ascertain  the  existence  of  a  febrile 
action,  which  becomes  manifest  in  its  exacerbations  and  is  discov- 
erable even  in  its  remissions.  The  same  is  true  of  that  scarcely 
noticeable  febrile  action  which  accompanies  typhoid  fever  during 
the  first  week,  and  sometimes  even  through  its  entire  course,  when 
it  assumes  its  mildest  form. 

The  phenomena  of  hectic  fever,  in  certain  cases,  (and  almost 
always  at  its  commencement,)  are  for  a  considerable  time  obscure 
and  of  difficult  appreciation.  It  does  not  cause  that  disorder  in 
the  system  which  belongs  to  acute  febrile  action.  The  latter  in- 
stantly produces  general  indisposition,  loss  of  appetite,  and  con- 
fines the  patient  to  bed ;  while  hectic  fever,  especially  during  its 
first  period,  does  not  at  all  affect  the  habits  of  life ;  the  strength  and 
flesh,  it  is  true,  diminish  gradually,  but  most  frequently  the  patient 
pursues  his  occupations,  eats  and  digests  nearly  as  usual ;  some- 
times even,  he  does  not  perceive  the  slightest  change  in  his  health. 
This  is  particularly  observed  in  the  course  of  certain  diseases  of 
the  chest,  when  the  pulse  begins  to  be  accelerated,  the  thirst  to 
increase,  and  the  sleep  to  be  accompanied  by  morning  perspira- 
tions. In  these  cases,  the  knowledge  of  the  existence  of  com- 
mencing hectic  fever,  is  frequently  the  most  important  point  in 
establishing  the  diagnosis  of  a  tuberculous  affection.* 

3.  Difficult  Diagnosis  resulting  from  the  Infrequency  of  the  Dis- 
ease. —  If  those  diseases  be  excepted  which  are  seated  upon  the 
external  surface,  or  in  parts  which,  although  situated  somewhat 
profoundly,  may  yet  be  directly  examined  by  the  aid  of  our  ex- 
plorative means;  we  repeat,  if  these  diseases,  whose  diagnosis  is 

*  Although  hectic  fever  is  connected  with  tuberculous  affections  in  so  great  a 
majority  of  cases,  that  its  mention,  alone,  suffices  most  frequently  to  bring  to  mind 
its  formidable  companion,  (or,  more  properly  speaking,  its  cause,  considering  hectic 
fever  as  a  symptom  or  assemblage  of  symptoms;)  yet  it  should  be  remembered 
that  many  other  affections  or  practices  induce  a  species  of  hectic  fever.  Authors 
have  enumerated  several  varieties ;  as  Gastric,  Pectoral,  Genital,  Hamorrhagic, 
Cutaneous,  Moral,  eic.  (Broussais)  :  Inflammatory,  Putrid,  Nervous,  Gastric, 
Atrabilious,  Piluitous,  Verminous,  Enter  o-mesenteric,  and  Suppurative.  (Hilden- 
brand.)  To  these,  puerperal  hectic  is  added  by  Dr.  Copland.  —  (Med.  Diet. 
Hectic  Fever.)  Of  these  various  forms,  the  genital,  hamorrhagic  and  moral  seem 
most  constantly  inclined  to  merge,  finally,  in  the  pectoral,  which  deservedly  occu- 
pies the  first  rank  in  point  of  frequency.  The  other  varieties,  depending  upon 
special  and  evident  causes,  disappear  with  their  removal,  and  rarely  terminate  in 
the  pectoral,  which  may,  (if  we  may  hazard  the  opinion,)  be  considered  the  only 
incurable  variety,  depending  as  it  does,  nearly  always,  upon  causes  incapable  of 
removal.  The  suppurative  form  may  be  considered  as  next  in  point  of  fatality, 
but  cannot  compare  with  the  pectoral.  The  gastric  disorder  accompanying  pecto- 
ral hectic  can  hardly  be  considered  as  indicating  the  termination  of  the  gastric  in 
the  pectoral  variety.  —  TRANS. 


DIAGNOSIS.  337 

generally  quite  easy,  because  they  are  evident  to  our  senses,  be  set 
aside,  we  must  admit  that,  generally,  the  more  rare  a  disease  is, 
the  less  it  is  understood,  and  consequently  its  diagnosis  is  more 
obscure.  This  proposition  needs  no  proof.  The  most  highly  edu- 
cated physician,  when  confronting  a  disease  he  has  never  observed 
or  heard  described,  and  of  which,  perhaps,  there  exists  no  example 
in  the  annals  of  the  science,  will  often  experience  insurmountable 
difficulties  in  its  diagnosis.  Such  was  the  position  of  Boerhaave* 
when  called  to  visit  Admiral  Wassenar,  laboring  under  the  dread- 
ful symptoms  of  transverse  rupture  of  the  oesophagus.  Post-mor- 
tem examination  alone  revealed  the  material  lesion  productive  of 
symptoms  equally  frightful  and  unusual. 

It  is  not  only  in  cases  where  the  signs  of  a  disease  and  its  very 
existence  are  unknown,  that  diagnosis  is  difficult  or  impossible ; 
these  difficulties,  this  almost  impossibility,  exist  in  certain  very  rare 
affections,  whose  anatomical  nature  and  symptoms,  however,  are 
recognised  when  they  have  signs  in  common  with  another  disease 
daily  observed  by  the  physician.  In  fact,  when  a  group  of  symp- 
toms belongs  to  two  affections,  one  of  which  is  very  frequent,  and 
the  other  as  rare,  the  physician  will,  and  naturally  should,  be  led 
to  apply  these  symptoms,  whenever  presented,  to  the  most  common 
disease.  If,  for  example,  in  a  case  of  chronic  disease,  one  side  of 
the  thorax  present,  in  a  limited  space,  (which  is  constantly  the 
same  whatever  be  the  attitude  of  the  patient,)  a  flat  sound  and 
entire  absence  of  the  respiratory  murmur,  without  fever,  and  with 
medium  loss  of  flesh,  we  may  suspect  two  different  lesions :  either 
there  is  pleuritic  effusion  circumscribed  by  adhesions,  which  is  of 
daily  occurrence,  or  a  solid  tumor  developed  in  the  pleura  or  in 
the  pulmonary  parenchyma,  some  examples  of  which  are  con- 
tained in  the  records  of  the  science.  The  latter  does  not,  perhaps, 
occur  in  greater  proportion  to  the  former,  than  one  to  one  hundred 
thousand  ;  therefore  when  the  exceptional  case  presents  itself,  it 
will  almost  inevitably  become  the  source  of  error  in  diagnosis, 
especially  if  the  physician  have  not  been  summoned  at  the  com- 
mencement of  the  disease,  or  if  the  exploration  of  the  chest  was 
not  scientifically  made.  The  unequal  frequency  of  diseases  neces- 
sarily constitutes  one  of  the  elements  of  diagnosis ;  it  sometimes 
renders  it  more  obscure,  but  in  most  cases  it.  is  highly  serviceable  to 
the  physician,  when  the  inductions  furnished  by  it  are  employed 
with  proper  reserve. 

4.  Complications  generally  embarrass  diagnosis,  either  because 
the  symptoms  of  one  disease  encumber  or  obscure  those  of  the  other, 
or  because  the  mingling  of  these  phenomena  changes  simultaneously 
the  physiognomy  of  both  affections,  so  that  neither  of  them  exhibits 
its  usual  characteristics.  There  is  rarely  error  in  regard  to  both 
diseases  at  once  ;  but  it  often  happens  that  one  of  them  is  misun- 
derstood, and  that  the  phenomena  appertaining  to  the  other  disease 
are  referred  to  sympathetic  disturbance  of  the  functions.  This 
error  may  usually  be  avoided,  by  recollecting,  that  in  order  to 
form  an  accurate  diagnosis,  we  must  not  only  ascertain  the  actual 
29 


338  DIAGNOSIS. 

disease,  but  also  be  sure  that  no  other  exists.  By  such  a  method 
of  examining  patients,  obscure  complications  will  frequently  be 
detected,  and  sometimes  even,  we  may  be  led  to  perceive  in  that  at 
first  regarded  as  the  unique  and  essential  disease  but  a  symptom 
or  consecutive  lesion  of  one  subsequently  distinguished. 

5.  There  is  still  another  condition  which  greatly  enhances  the 
difficulties  of  diagnosis :  this  is  deception  on  the  part  of  individuals 
*vho  wish  either  to  conceal  the  diseases  under  which  they  labor 
(maladies  dissimuttes),  or  to  induce  the  physician  to  suppose  others, 
really  non-existent  (maladies  simulees). 

It  is  quite  common  for  individuals  to  seek  to  conceal  from  the 
physician  the  diseases  which  affect  them  :  a  false  modesty,  fear  of 
blame,  or  a  wish  to  retain  or  obtain  employment,  are  the  most 
usual  causes  of  such  dissimulation.  But  it  far  more  frequently 
happens  that  individuals  complain  of  diseases  which  they  have 
not,  for  the  purpose  of  obtaining  something  desired,  or  avoiding 
something  apprehended.  The  talented  author  of  Guzman  d'Al- 
farache  has  exposed  the  greater  part  of  the  tricks  practised  by 
mendicants  to  excite  the  public  commiseration.  The  wish  to  avoid 
military  service  often  leads  young  men  to  feign  various  diseases. 
Many  persons  indicted  for  criminal  offences  have  feigned  derange- 
ment in  order  to  escape  impending  condemnation. 

Some  of  these  simulated  diseases  may  take  place  without  the 
slightest  disturbance  of  the  health;  an  individual  in  perfect  health 
may  feign  paroxysms  of  intermittent  fever  with  general  tremor  and 
chattering  of  the  teeth,  rheumatic  or  nervous  pains,  loss  of  one  of 
the  senses,  as  hearing  or  sight,  apoplexy,  epilepsy,  hysteria,  mania 
and  incontinence  of  urine.  There  are  other  affections  which  can- 
not be  simulated  except  by  determining  a  disease  resembling  them, 
but  which  is  very  slight :  such  is  the  kind  of  fever  produced  by 
the  internal  use  of  excitants,  by  the  introduction  of  garlic  or  to- 
bacco into  the  rectum,  etc:  cutaneous  diseases  are  simulated  by 
the  application  of  rubefacients,  elephantiasis  by  insufflation  of  air 
into  the  cellular  tissue,  cancer  of  the  mammae  by  the  use  of  certain 
topical  irritants,  etc. 

Jt  is  very  difficult  to  ascertain  a  concealed  disease,  except  it  de- 
termine a  remarkable  change  in  the  external  appearance,  or  that 
the  friends  of  the  patient  oblige  him  to  consult  a  physician.  If 
the  disease  present  external  signs,  the  successive  examination  of 
the  various  parts  may  lead  to  its  detection.  If  those  signs  be 
wanting,  if,  for  instance,  concealed  grief  be  the  cause  of  settled 
decline,  the  diagnosis  is  very  difficult  so  long  as  the  patient  obsti- 
nately refuses  to  reveal  his  ailment. 

The  sagacity  of  physicians,  however,  has  on  many  occasions 
surmounted  these  obstacles.  We  even  now  admire  the  penetration 
of  Erasistratus  in  discovering  the  secret  cause  of  the  illness  of 
Antiochus,  and  the  address  with  which  he  succeeded,  contrary  to 
all  expectations,  in  restoring  him  to  health,  by  obtaining  for  him 
the  hand  of  Stratonice. 

The  distinction  is  usually  more  easy  in  simulated  diseases.    The 


DIAGNOSIS.  339 

peculiar  situation  of  the  individuals,  the  knowledge  of  those  things 
which  they  necessarily  fear  or  desire,  and  their  relations  to  those 
around  them,  often  communicate  the  first  suspicion  to  the  physi- 
cian, and,  most  frequently,  when  he  is  deceived,  it  is  because  the 
fraud  has  not  been  suspected.  In  some  cases,  however,  the  diffi- 
culty is  very  great,  especially  when  he  who  wishes  to  deceive 
perfectly  understands  the  part  he  is  to  play,  and  has  great  interest 
in  sustaining  it.  Mahon  has  related  a  very  striking  example  o£ 
this  sort.*  A  young  soldier,  with  the  intention  of  quitting  the 
service,  feigned  total  loss  of  vision.  The  fraud  was  suspected  ; 
he  was  consequently  subjected  to  the  most  painful  treatment, 
while  every  means  were  put  in  requisition  to  expose  the  deception. 
Various  attempts  having  proved  useless,  the  following  was  tried 
as  the  last  resort.  He  was  stationed  at  a  few  paces  distance  from 
a  deep  river  and  ordered  to  walk  straight  forward ;  this  he  did 
without  hesitation  and  allowed  himself  to  fall  into  the  river.  After 
this  trial,  he  was  still  retained,  with  a  promise  of  release  on  confess- 
ing the  truth ;  he  refused  for  a  long  time,  but  finally,  convinced  of 
the  sincerity  of  those  who  promised,  he  took  up  a  book  and  read. 

The  means  employed  for  distinguishing  simulated  diseases 
vary  according  to  circumstances.  The  very  attentive  examina- 
tion of  all  the  phenomena  usually  leads  to  the  detection  of  the 
fraud ;  most  simulated  diseases,  indeed,  have  but  an  imperfect 
resemblance  to  the  real  affections  ;  there  is  always  something  un- 
usual which  does  not  escape  the  practised  eye.  Feigned  diseases 
very  closely  resemble  flowers  and  fruit  attached  to  trees  which 
do  not  produce  them:  ordinary  observers  may  be  deceived,  but 
the  expert  botanist  is  not  the  dupe  of  such  an  artifice. 

An  individual  who  endeavors  to  feign  a  disease,  rarely  foresees  all 
the  questions  that  may  be  addressed  to  him  upon  the  course  and 
succession  of  the  phenomena  which  he  has  experienced  ;  taken 
unawares  on  many  points,  he  hesitates  in  his  first  replies  ;  if  inter- 
rogated a  second  time  in  regard  to  the  same  things,  his  memory 
fails  him,  especially  when  the  questions  have  been  numerous :  if 
he  do  not  betray  himself  in  his  answers,  he  can,  in  most  cases, 
be  led  to  say  things  in  regard  to  the  progress  of  his  complaints, 
which  are  in  such  complete  opposition  to  daily  observation,  that 
they  expose  the  deceit  in  the  surest  manner. 

If  all  this  should  prove  insufficient,  the  individual  suspected  of 
feigning  disease  might  be  submitted,  for  one  or  more  days,  to  rigid 
diet.  This  plan,  which  is  wonderfully  efficacious  with  children,  is 
likewise  of  great  service  in  hospitals,  especially  where  active  su- 
pervision prevents  the  individuals  submitted  to  such  a  kind  of 
proof  from  procuring  food,  which  is  far  more  difficult  than  is  gen- 
erally supposed.  We  might,  however,  announce  to  the  patients 
that  it  will  be  requisite,  if  the  disease  persist,  to  resort,  without  de- 
lay, to  painful  measures,  as  blisters,  setons,  and  moxas ;  the  incon- 
veniences of  these  means  might  be  exaggerated,  and  we  might 

*  MAHON,  Medecine-legale,  torn.  i. 


340 


DIAGNOSIS. 


even  proceed  to  apply  them,  because  they  are  indicated  if  the 
disease  really  exist,  and  because,  if  the  disease  be  feigned,  the 
patient  will  not  submit  to  their  use,  especially  if  it  be  necessary  to 
repeat  them.  Finally,  one  means,  nearly  always  successful  with 
females  who  simulate  hysterical  attacks,  is  the  prescription  of  a 
large  blister  over  parts  which  are  habitually  uncovered,  as  the 
nape  of  the  neck,  or  even  the  throat  and  chest :  the  pandiculation 
ind  yawning  which  usually  terminate  the  attack  immediately 
take  place,  and  the  patient  recovers  herself  before  the  prescription 
can  be  executed.  If  simulated  diseases  are  more  frequent  in  fe- 
males than  in  males,  as  Morgagni  *  has  remarked,  the  vanity 
peculiar  to  their  sex  supplies  the  physician  with  additional  means 
of  discovering  the  deception. — 


*  Sexus  ad  fallendum  pronus. 

[Feigning  of  Disease. — This  subject,  which  must  always  be  of  very  great  in- 
terest to  the  physician,  is  somewhat  differently  considered,  as  to  its  divisions,  by 
various  authors.  The  distinction  drawn  by  Chomel  between  concealed  and  simu- 
lated diseases  (Maladies  Dissimulees,  Maladies  Simulees,  p.  338),  seems  well 
founded  and  desirable.  Nysten  and  Dunglison  consider  the  terms  as  synonymous, 
and  the  latter  groups  all  diseases  of  the  deceptive  class,  under  the  appellation 
"  Feigned  Diseases,"  of  which  he  gives  a  very  complete  list,  with  the  mode  of 
imposture  and  means  of  detection  :  this  list,  which  is  far  more  complete  than  the 
enumeration  of  our  author,  should  be  referred  to  in  this  connection.  —  (Dunglison, 
Med.  Diet  Feigned  Diseases.) l  A  highly  interesting  and  complete  account  of 
Feigned  Diseases  and  the  ingenious  methods  adopted  for  their  detection,  etc.,  is 
contained  in  Copland's  Med.  Dictionary,  art.  F.  Diseases.  Soldiers,  who  are 
also  termed  "  malingerers,"  and  sailors,  known  as  "  skulkers,"  with  mendicants 
and  prisoners,  constitute  the  larger  number  of  such  impostors.  But  names  of 
greater  note  "  grace"  (to  use  the  expression  of  Dr.  Copland)  that  class  of  "  ma- 
lingerers "  who  wish  to  accomplish,  by  such  procedures,  any  object  of  private  or 
political  ambition,  or  to  compass  any  particular  end.  Among  these  are  mentioned 
Amnon  the  son  of  David,  Ulysses,  Solon,  the  elder  Brutus,  etc.  ;  and  in  later 
times,  Northumberland,  the  Earl  of  Essex,  and  Raleigh.  In  addition  to  the  de- 
scription in  "  Guzman  d'Alfarache,"  the  ingenious  devices  employed  by  the 
Parisian  mendicants  to  obtain  the  means  of  existence  are  graphically  described  by 
Victor  Hugo  in  his  Notre  Damede  Paris,  chap.  vi.  :  the  revelations  of  the  "  Cour 
des  Miracles  "  are  at  once  astonishing,  ludicrous  and  thrilling.  Feigning  has 
been  suspected,  when  actual  disease  existed,  as  was  proved  by  post-mortem  exami- 
nation —  (Copland.)  This  should  render  the  physician  scrupulous  in  regard  to  a 
hasty  verdict.  Hysteria  may  be  real,  although  sternutatories,  as  recommended  by 
Dunglison,  produce  their  usual  effect.  "Detection  is  by  no  means  easy."  (Cop- 
land.) The  "concise  rules  for  the  detection  of  feigned  and  factitious  diseases, 
from  Guy's  Forensic  Medicine,"  (Copland,  Op.  Cit.  Dr.  Lee,}  should  be  familiar 
to  the  practitioner.  External,  are  more  frequently  feigned  than  internal,  diseases, 
for  the  obvious  reasons  that  they  are  more  constantly  manifest  and  more  easily 
simulated. 

We  now  possess  an  agent  of  unlimited  power,  as  it  would  seem,  in  the  detec- 
tion of  feigned  diseases  ;  viz.  the  inhalation  of  the  vapor  of  sulphuric  ether ;  whether 
its  efficacy  be  shown  as  a  revealer  of  external  alterations,  by  enabling  the  physi- 
cian to  examine  the  body  more  carefully  and  easily,  the  patient  being  in  a  state  of 
insensibility,  or  in  removing,  as  if  by  magic,  the  factitious  deformities  of  the  body 
itself,  which,  by  long  practice,  the  patient  is  enabled  to  produce  at  will  and  pre- 
serve for  an  indefinite  period.  The  only  cases  which  we  have  as  yet  noticed  of 

1  Synonymes  :  —  Simulated  Diseases  ;  Pretended  Diseases  ;  Feigned  Diseases  ;  Excited 
Diseases.  —  (Fr.)  Maladies  dissimulees.  M.  simulees.  M.  feintes.  M.  supposees.  —  (Dun- 
glison.) M.  dissimulees.  M.  simulees.  —  (Nysten.  Diet.  Med.) 


PROGNOSIS.  341 

CHAPTER   XVII. 

PROGNOSIS.* 

PROGNOSIS  is  the  previously  expressed  opinion  in  regard  to  the 
changes  about  to  supervene  in  the  course  of  a  disease. 

It  is  that  part  of  medical  science  which  gains  most  reputation 
for  a  physician  among  a  large  class,  who,  not  capable  of  appre- 
ciating accuracy  of  diagnosis,  are  always  able  to  verify  an  opinion 
given  as  to  the  duration  and  result  of  a  disease.  On  this  account 
nothing  is  better  suited  to  win  the  confidence  of  the  patient  and 
his  attendants,  than  a  confirmation  of  the  prognosis  by  after  events, 
and  nothing  injures  the  physician's  reputation  more  than  error  in 
this  respect. 

Prognosis  does  not  consist  alone  in  foretelling  that  a  disease  will, 
or  will  not,  prove  fatal ;  it  enables  us  to  recognize,  among  affections 
which  are  not  fatal,  those  which  will  terminate  in  complete  restor- 
ation to  health,  those  which  will  remain  stationary,  and  those 
which  will  diminish  or  increase  gradually  during  life,  at  periods 
which  we  can  sometimes  determine.  Prognosis  is  also  applicable 
to  the  accidental  symptoms  which  may  supervene,  such  as  deliri- 
um and  convulsions ;  likewise  to  the  period  when  the  disease  will 
terminate,  sometimes  even  to  the  critical  and  consecutive  phenom- 
ena and  the  danger  of  relapse  and  recurrence. 

§  I.  The  necessary  conditions  on  the  part  of  both  physician  and 
patient,  in  order  to  the  greatest  accuracy  in  prognosis,  are  the  same 
that  have  been  mentioned  in  regard  to  diagnosis,  (p.  275.) 

When  we  notice,  from  the  earliest  days  of  medicine,  (a  time  when 
the  diagnosis  of  most  diseases  was  incomplete  or  erroneous.)  that 
rules  for  prognosis  were  established  by  observers,  which  are  cited 
as  models  in  our  times;  and  likewise  that  persons  almost  wholly 
unacquainted  with  medical  knowledge,  especially  those  who  devote 
their  time  to  attendance  upon  the  sick,  exhibit  daily  a  certain  skill 
in  foreseeing  the  issue  of  diseases,  we  might  be  led  to  conclude  that 
diagnosis  possesses  only  a  secondary  utility  in  forming  prognosis, 
but  we  should  be  greatly  deceived. 

this  application  of  ethereal  inhalation,  are  reported  from  M.  Baudens  in  the  Medical 
Gazette  for  March  19th,  1847.  These  were  cases  of  conscripts  suspected  of 
feigning  diseases  for  the  purpose  of  avoiding  service.  One  of  them  had,  appa- 
rently, outward  curvature  of  the  spine  in  a  marked  degree.  Inhalation  produced 
total  disappearance  of  the  deformity.  The  other  case  illustrates  the  advantage  to 
be  derived  from  the  use  of  ethereal  inhalation  where  feigning  is  suspected  but 
disease  actually  exists,  as  has  been  previously  noticed.  The  person  was  supposed 
to  feign  anchylosis  of  the  hip-joint.  Relaxation  of  the  muscles  was  the  result  of 
inhalation,  but  the  reality  of  the  anchylosed  slate  was  proved  by  thorough  exami- 
nation. —  TRANS.] 

*  HooyviaOig  ;   7156,  before  ;  yu'wGxo),  I  know. 

29* 


342  PROGNOSIS. 

There  are,  it  is  true,  certain  cases  in  which  the  first  glance  at 
the  patient  enables  us  to  judge  immediately  of  his  danger,  even 
before  we  ascertain  the  disease  by  which  he  is  attacked ;  but  in 
the  first  place,  these  cases  are  not  the  most  common,  and  even  in 
these,  where  prognosis  seems  so  clear,  a  thorough  examination  of 
the  patient  is  by  no  means  superfluous.  Oftentimes,  when  the 
diagnosis  has  been  established,  it  is  discovered  that  the  original 
gpinion  in  regard  to  the  gravity  of  the  disease  must  be  rectified. 
Certain  fatal  affections  declare  themselves  by  their  diagnostic  signs 
a  long  time  before  the  face  presents  any  indicative  impression,  and 
some  affections  not  dangerous  in  their  nature,  as  for  example, 
anaemia,  and  certain  intestinal  pains,  alter  very  much  the  color  of 
the  skin,  and  also  the  features,  while  the  prognosis  is  far  from  un- 
favorable. A  thorough  knowledge  of  diseases  is  to  the  physician 
an  indispensable  condition  in  properly  establishing  his  prognosis; 
we  may  even  add,  that  in  order  to  acquire  great  skill  in  prognosis, 
more  time  and  experience  are  requisite  than  for  accurate  diagnosis. 
Prognosis,  indeed,  often  presents  great  difficulties  in  cases  where 
diagnosis  has  none,  and  in  those  where  diagnosis  is  obscure,  prog- 
nosis is  likewise  necessarily  so.  If  we  except  those  cases  where 
there  can  be  but  one  termination,  (and  these  are  the  rarest  cases,) 
prognosis  is  always  a  delicate  question  in  diseases  of  a  certain 
degree  of  gravity,  and  especially  in  acute  diseases.  In  order 
to  form  it.  the  physician  is  obliged  to  compare  the  case  he  is 
actually  observing,  with  all  the  analogous  cases  he  has  pre- 
viously observed ;  if  the  result  has  been  constantly  either  favorable 
or  unfavorable  in  all,  the  prognosis  cannot  be  doubtful ;  but  if  it 
has  been  at  one  time  favorable,  at  another  the  contrary,  it  is,  then, 
necessary  to  compare  the  various  conditions  which  have  accom- 
panied a  disease  apparently  similar  both  in  those  who  have  recov- 
ered and  those  who  have  died,  and  to  ascertain  to  which  of  these 
two  groups  the  case  in  question  should  be  assigned.  But  this 
comparison  of  cases  is  only  valuable  when  the  physician  has  pre- 
viously made  many  and  careful  observations.  Much  time  is 
required  in  order  to  understand  fully  all  the  forms  of  a  single  dis- 
ease, all  their  tendencies,  and  all  the  accidents  which  may  disturb 
its  course,  and  this  practical  knowledge  is  a  necessary  element  in 
prognosis.  A  few  years  devoted  to  clinical  study  may  suffice  to 
enable  one  to  form  a  correct  diagnosis ;  but  to  acquire  excellence 
in  prognosis,  which  does  not  consist,  like  diagnosis,  in  the  appreci- 
ation of  existing  facts,  but  in  foreseeing  future  events,  an  entire  life 
devoted  to  observation  scarcely  suffices  to  accumulate  the  mass  of 
facts  necessary  for  the  solution  of  the  complex  problems  which  are 
daily  presented  to  the  physician ;  in  many  cases,  moreover,  even 
the  longest  and  most  enlightened  experience  only  enables  us  to 
avoid  an  erroneous  opinion,  and  to  establish  with  more  precision 
the  various  chances  appertaining  to  each  particular  case. 

§  II.  Under  the  term  prognostic  signs  is  comprised  all  which 
may  enlighten  the  judgment  of  the  physician  upon  the  future  course 


PROGNOSIS.  343 

of  the  disease ;  they  are  to  be  discovered  in  the  most  exact  appre- 
ciation possible  of  the  actual  state  of  the  patient,  and,  consequently, 
of  what  has  preceded,  while  forming  the  diagnosis.  Diagnosis  isj 
in  fact,  the  original  and  chief  basis  of  prognosis.  If  diagnosis  be 
obscure,  prognosis  is  uncertain.  It  is  only  when  diagnosis  is  clear 
and  complete,  that  is  to  say,  when  it  comprehends  all  its  con- 
stituent elements  (p.  311),  that  prognosis  can  and  should  be  estab- 
lished, according  to  the  cases,  at  one  time  positively,  at  another, 
with  reserve,  and  with  a  methodical  appreciation  of  the  various 
chances  presented  by  the  disease.  Independently  of  the  prognostic 
signs  afforded  by  the  seat  and  nature  of  the  disease,  the  physician 
will  find  still  others  in  its  natural  tendency  towards  various  termi- 
nations, in  the  degree  of  efficacy  of  remedial  measures,  in  the  pe- 
culiar conditions  relative  to  age,  sex,  constitution,  causes  of  the 
disease,  antecedent  phenomena,  mode  of  attack,  course,  duration, 
effect  of  remedies  first  employed,  and,  in  certain  cases,  complica- 
tions and  epidemics.  Finally,  without  attaching  so  much  impor- 
tance to  particular  symptoms  as  most  authors  on  semeiology  have 
done,  we  still  think  it  our  duty  to  glance  rapidly  at  the  prognostic 
value  of  the  principal  symptoms. 

1.  It  is  hardly  necessary  to  enlarge  upon  the  proposition  already 
stated,  viz.,  that  prognosis  is  based  upon  diagnosis,  understanding 
diagnosis  to  be  the  exact  knowledge  of  the  disease  in  regard  to  its 
material  lesions  and  symptomatic  phenomena. 

The  character  of  the  lesion,  when  one  exists,  and  the  degree  of 
its  development,  are,  in  connection  with  the  extent  of  such  lesion, 
the  primary  conditions  of  prognosis.  A  lesion  inflammatory  in  its 
nature,  is  not,  in  general,  at  all  serious,  when  it  occupies  an  organ 
of  minor  importance  and  for  a  limited  extent ;  it  becomes  more 
serious  when  its  extent,  both  superficial  and  profound,  is  increased, 
and  when  seated  in  a  part  whose  functions  are  more  important. 
In  herpes  zoster,  which  is  wholly  exempt  from  danger;  in  general 
peritonitis,  which  is  almost  constantly  fatal,  the  prognosis  is  easy. 
In  visceral  inflammations,  whose  termination  is  most  frequently 
favorable,  though  sometimes  the  contrary,  the  prognosis  should  be 
formed  with  great  reserve,  in  order  equally  to  avoid  inspiring  the 
patient's  attendants  with  too  great  security,  or  excessive  anxiety. 
The  prognosis  is  still  more  difficult  and  delicate  in  certain  affec- 
tions, as  the  eruptive  fevers,  in  which  a  deleterious  agent,  existing 
in  the  system,  may  at  any  moment  occasion  formidable  accidents, 
which  nothing  seemed  to  indicate,  and  which,  in  many  cases,  are  in 
no  wise  explained  on  post-mortem  examination.  But  of  all  acute 
affections,  typhoid  fever  presents  the  most  difficulty  in  regard  to 
prognosis ;  in  this  disease,  we  at  one  time  behold  the  most  formida- 
ble accidents  terminate  favorably,  and  again,  the  mildest  symptoms 
in  appearance,  become  suddenly  exasperated  and  terminate  in 
deatli.  This  sudden  exacerbation  is  sometimes  caused  by  perfo- 
ration of  the  intestine. 

In  those  diseases  called  organic,  the  prognosis  is  generally  easy ; 
when  once  the  disease  is  ascertained,  there  can  remain  no  doubt  as 


344  PROGNOSIS. 

to  its  future  course,  and  its  definitive  termination.  Tubercle  and 
cancer  never  retrograde,  and  their  progressive  extension  most  fre- 
quently induces  marasmus  and  death.  The  difficulty  of  prognosis 
in  this  case  consists  only  in  the  appreciation  of  the  time  during 
which  the  struggle  will  continue. 

The  degree  of  development  attained  by  the  lesion  is  likewise 
highly  important  in  prognosis.  Pneumonia  in  its  third  stage  is 
generally  fatal;  and  necessarily  so,  if  it  occupy  a  considerable 
portion  of  the  pulmonary  parenchyma.  Softened  tubercles  and 
ulcerated  cancer  cause  more  immediate  anxiety  than  crude  tuber- 
cle arid  scirrhus. 

The  seat  of  the  disease  has  likewise  great  value  in  prognosis. 
The  lesion  being  the  same,  the  danger  is  necessarily  subordinate 
to  the  importance  of  the  affected  part  and  the  extent  to  which  it  is 
affected. 

The  local  and  general  symptomatic  phenomena,  which,  as  we 
have  seen,  are  very  valuable  in  a  diagnostic  point  of  view,  furnish, 
moreover,  very  important  signs  for  prognosis.  Excessive  dyspnoea 
in  thoracic  inflammations,  considerable  irregularity  in  the  pulse  in 
pericarditis,  and  frequent  vomiting  in  gastritis,  add  greatly  to  the 
gravity  of  the  prognosis.  In  every  acute  disease,  general  phenom- 
ena of  a  grave,  adynamic  or  ataxic  nature  are  replete  with  danger. 

2.  The  powers  of  nature,  and  of  our  science,  are  to  be  well  con- 
sidered in  prognosis.     A  large  number  of  chronic  diseases,  con- 
nected with  deep-seated  organic  lesion,  resist  every  effort  of  nature 
or  art :  of  this  number  are  organic  affections.     There  are  other 
diseases  in  which  nature  alone  is  almost  constantly  powerless,  as 
cataract,  vesical  calculi  and  syphilis,  and  in  which  the  interference 
of  art  can  secure  recovery.     In  some  cases,  as  in  malignant  inter- 
mittent fevers,  death  is  the  inevitable  and  prompt  termination  of 
the  disease,  if  artificial  means  are  not  resorted  to.     The  efficacy 
of  quinine  in  intermittent  diseases  greatly  diminishes  the  gravity 
of  the  prognosis  in  affections  presenting  this  type.     Lastly,  there 
are  other  diseases,  where  the  concurrence  of  natural  and  artificial 
means  can,  in  most  cases,  (although  not  in  all,)  lead  to  the  recov- 
ery of  health,  as  is  observed  in  severe  fevers  and  in  visceral  in- 
flammations. 

3.  The  peculiar  conditions  of  sex  and  constitution  must  not  be 
neglected  in  a  prognostic  point  of  view ;  but  the  age,  the  previous 
good  or  bad  health,  and  the  physical  and  moral  causes  which  have 
affected  the  organization,  furnish  far  more  important  prognostic 
signs. 

Other  things  being  equal,  an  acute  disease,  and  especially  an 
inflammation  supervening  in  a  strong  and  well  constituted  indi- 
vidual, who  had  previously  enjoyed  good  health,  is  far  more  likely 
to  terminate  favorably  than  when  it  appears  under  opposite  condi- 
tions. 

In  similar  circumstances,  age  presents  results  no  less  remarka- 
ble. Diseases  are  generally  more  severe  and  more  frequently 
fatal  at  the  extreme  periods  of  life,  with  this  difference,  that  in 


PROGNOSIS.  345 

early  infancy,  the  most  violent  affections  are  never  entirely  hope- 
less ;  infancy  is  the  age  of  resurrections ;  the  well  known  adage 
ubi  vita,  ibi  spes,  is  applicable  to  infancy;  while  in  the  aged,  acute 
diseases,  when  they  assume  a  grave  form,  almost  inevitably  termi- 
nate in  death.  In  adult  age,  the  changes  are  more  favorable,  and 
still  more  so  in  youth  and  early  manhood.  Pneumonia  is  one  of 
the  most  remarkable  examples  of  this  fact.  According  to  the 
clinical  records  of  the  Hotel  Dieu,  the  mortality  in  this  disease  is 
less  than  one  twentieth  in  those  from  fifteen  to  twenty  years  of  age, 
it  is  about  one  fourth  in  adult  age,  and  one  half  in  patients  of 
sixty  years  and  upwards.  There  are,  however,  certain  diseases 
to  which  these  considerations  are  not  applicable.  The  eruptive 
fevers,  for  example,  are  less  dangerous  in  infancy,  and  some  or- 
ganic affections,  as  scirrhus  and  tubercle,  most  frequently  remain 
stationary,  or,  at  least,  progress  more  slowly  in  the  aged. 

There  is  an  hereditary  condition  which  renders  certain  diseases 
much  more  grave,  or  even  constantly  fatal,  in  nearly  all  the  mem- 
bers of  the  same  family.  This  remark,  made  by  Meara,  is  con- 
firmed by  the  observations  of  Morton,  who  has  seen  variola  * 
quite  as  dangerous  in  certain  families  as  the  plague. 

The  diseases  developed  in  females  at  the  period  of  menstrua- 
tion, and  especially  during  pregnancy,  are,  in  general,  more  severe. 
In  the  first  case,  suppression  of  the  menstrual  discharge,  or  uterine 
haemorrhage,  often  supervenes;  in  the  second,  abortion  frequently 
takes  place,  and  this  circumstance,  which  nearly  always  proves 
fatal  to  the  child,  aggravates  in  every  way  the  condition  of  the 
mother,  and  frequently  results  in  her  death. 

The  puerperal  state  adds  very  much  to  the  danger  of  those 
acute  diseases  which  supervene  dtfring  its  continuance;  serous 
arid  parenchymatous  inflammations  pass  rapidly  into  the  suppura- 
tive  stage,  and  the  eruptive  fevers  often  appear  accompanied  by 
ataxic  or  adynamic  symptoms.  The  diseases  developed  under 
these  conditions  are  the  more  serious  in  proportion  to  their  prox- 
imity to  the  moment  when  delivery  took  place.  Observation  has 
shown  that  a  severe  chill,  supervening  immediately  after  delivery, 
denotes  the  invasion  of  an  acute  disease,  whose  termination  will 
almost  always  be  unfavorable  and  sudden.  If  the  disease  does 
not  appear  for  several  days,  the  prognosis  will  be  far  less  serious, 
and  still  less  so,  if  one  or  two  weeks  elapse  between  the  labor  and 
the  onset  of  the  disease. 

Habitual  intemperance  adds  infinitely  to  the  unfavorable  circum- 
stances of  disease.  Many  physicians  have  observed  that  the  acute 
affections  which  supervene  in  the  intemperate  are  almost  con- 
stantly fatal.  Habitual  excess  in  eating  adds  likewise  to  the 
danger,  but  in  a  less  degree.  Those  diseases  which  succeed  a 
long  famine,  or  the  nearly  exclusive  use  of  food  of  a  bad  quality, 
or  not  sufficiently  nutritive,  usually  terminate  unfavorably.  Asce- 
tics, who  use  a  diet  almost  entirely  vegetable  during  Lent,  incur 

*MORTON,  de  VarioUs,  chap.  vi. 


346  PROGNOSIS. 

far  more  danger  in  those  acute  diseases  with  which  they  may  be 
attacked,  after  this  long  abstinence. 

Excessive  evacuations,  considerable  and  prolonged  fatigue,  ex- 
cessive venereal  indulgence,  the  practice  of  masturbation,  watch- 
ings,  unremitting  mental  labor,  and  long  continued  grief,  are  all 
circumstances  nearly  always  rendering  the  course  of  diseases  unfa- 
vorable. We  have  observed  quite  a  number  of  grave  affections 
developed  in  individuals  who  had  recently  lost  an  employment 
upon  which  their  means  of  existence  depended  :  all  of  them  died. 

Habitual  ill  health,  and  chronic  disease  preceding  an  acute  affec- 
tion, in  like  manner  render  prognosis  more  unfavorable.  If  a 
circumscribed  inflammation,  as  erysipelas,  even  of  slight  intensity 
and  limited  extent,  be  developed  under  these  conditions,  we  most 
frequently  see  the  patients  sink  into  a  state  of  extreme  prostration 
and  die  in  a  few  days.  The  same  observation  is  applicable  to 
patients  just  recovering  from  an  acute  affection  which  has  greatly 
debilitated  them,  and  in  whom  a  new  disease  supervenes. 

Climate  and  season,  which  modify  the  course  and  duration  of 
certain  affections,  are  also  capable  of  varying  the  prognosis.  For 
this  reason,  dysentery  is  not  only  more  frequent,  but  also  far  more 
severe,  in  hot  than  temperate  climates,  while  syphilis,  which 
among  us  often  exhibits  grave  and  obstinate  symptoms,  is  in 
southern  climates,  on  the  contrary,  generally  mild  and  easily 
treated. 

4.  Precursory  phenomena  are  of  little  value  in  prognosis  :  when, 
however,  a  disease  is  preceded  by  loss  of  flesh,  which  has  increased 
progressively  for  several  months,  grave  symptoms  and  a  fatal  ter- 
mination may  be  apprehended. 

5.  The  manner  in  which  diseases  commence  merits  also  some 
attention :  those  whose  invasion  takes  place  by  violent  alternate 
chills  and  heat,  which  continue  for  one  or  more  days,  those  which 
begin  by  syncope,  violent  delirium,  arid  sudden  prostration,  most 
frequently  terminate  unfavorably  and  suddenly. 

It  should,  however,  be  remembered,  that  prognosis  can  rarely 
be  positively  established  at  the  commencement  of  diseases.  The 
successive  development  of  symptoms  is  quite  as  necessary  in  de- 
ciding the  opinion  of  the  physician  upon  the  ulterior  course  of  the 
disease,  as  upon  its  seat  and  nature.  Even  at  the  period  when 
diagnosis  is  no  longer  doubtful,  prognosis  will  often  still  remain  so, 
and  this  uncertainty  may  be  prolonged  even  to  the  last  period  of 
the  disease,  sometimes'  even  to  the  moment  when  death  dispels  all 
doubt  and  destroys  the  latest  hope.  In  the  midst  of  this  violent 
disturbance  of  the  organism,  where  the  danger  is  only  too  evident, 
prognosis  varies  necessarily  with  the  varying  disease.  The  skill 
of  the  physician  consists,  at  such  times,  in  carefully  appreciating 
the  different  elements  presented  to  his  observation,  in  calmly  ana- 
lyzing the  favorable  and  unfavorable  chances  in  the  daily  modifi- 
cations of  the  disease,  and,  lastly,  in  being  on  his  guard,  in  view  of 
the  great  changes  presented  by  the  symptoms,  against  a  deceptive 
security  and  a  premature  discouragement. 


PROGNOSIS.  347 

6.  The  progress  of  the  disease  is  of  some  importance  in  prog- 
nosis, especially  when  it  is  regular.     When  the  symptoms  increase 
gradually  in  intensity  beyond  the  ordinary  limits  of  the  period  of 
increase,  the  prognosis  is  unfavorable:  it  is  favorable,  on  the  other 
hand,   if  their  violence  diminish  from  day  to  day ;    it  is  almost 
always  uncertain  when  the  course  of  the  disease  is  irregular.     A 
sudden  change,  either  favorable  or  unfavorable,  is  far  less  impor- 
tant in  regard  to  the  prognosis  than  one  which  takes  place  slowly. 
The  latter  almost  always  announces,  with  certainty,  the  favorable 
or  unfavorable  termination  of  the  disease ;  while  a  sudden  ame- 
lioration is  always  suspicious,  as  likewise  a  sudden  aggravation, 
without  appreciable  cause,  is  generally  more  alarming  than  dan- 
gerous. 

7.  The  duration  of  the  disease  is  also  one  of  the  elements  of 
prognosis  :  neuralgia  of  many  years'  continuance,  old  arid  uncon- 
solidated  fracture,   and  dislocation  of  many  months'  standing,  are 
affections  nearly  always  incurable ;  when  recent,  on  the  contrary, 
they  generally  yield  to  the  treatment  employed. 

8.  The  influence  of  previous  treatment  deserves  much  attention : 
if  the  use  of  remedies,  properly  or  improperly  administered,  has 
been  followed  by  marked  improvement,  the  prognosis  is  favorable, 
but  if,   notwithstanding  the  treatment,  especially  when  most  dis- 
tinctly indicated,  the  disease  continues  to  progress  beyond  the  usual 
limits  of  its  period  of  increase,  it  is,   at  any  rate,  very  grave, 
although  it  may  not  necessarily  be,  on  that  account,  incurable  or 
fatal. 

9.  Complications  greatly  increase  the  gravity  of  the  prognosis ;  in 
the  first  place,  because  there  are,  at  once,  many  sources  of  danger, 
and  many  enemies  to  resist,  and  also  because,  in  many  cases,  each 
of  the  diseases  adds  to  the  gravity  of  the  other :  thus,  when  acute 
dysentery  is  complicated  with  cancer  of  the  large  intestines,  it  is 
more  dangerous,  because  developed  in  an  individual  already  ill, 
and  sometimes  exhausted,  and  the  progress  of  the  cancer  will  be 
hastened  by  the  acute  affection  of  the  intestine.     We  have  pre- 
viously indicated  the  gravity  of  erysipelas  when  it  supervenes 
upon  another  disease,  while  simple  erysipelas  is  almost  always 
without  danger. 

10.  When  a  disease  attacks  many  persons  simultaneously,  the 
prognosis  in  regard  to  each  particular  case  is  more  or  less  grave, 
in  proportion  as  the  actual  general  mortality  is  greater.     There 
are  certain  epidemics  in  which  the  inhabitants  are  less  severely 
affected  than  strangers,  females  less  so  than  males,  infants  than 
adults,  feeble  than  robust  persons,  and  vice  versa.     In  every  epi- 
demic, there  is  a  period  of  increase,  during  which  the  number  of 
patients  augments  daily,  and  the  disease   becomes  more  grave  in 
most  of  the  cases ;  a  period  of  violence,  during  which  the  number 
of  patients  and  the  severity  of  the  disease  are  at  their  maximum  ;  a 
period  of  decline,   when   both  diminish   simultaneously.     It  has 
likewise  been  observed  in  certain  epidemics,  that  there  was,  as  it 
were,  a  focus,  where  the  disease  appeared  in  all  its  energy,  and 


348  PROGNOSIS. 

that  in  proportion  to  the  distance  from  this  spot,  a  smaller  number 
of  individuals  were  attacked,  and  each  with  less  intensity.  These 
different  circumstances  should  be  taken  into  consideration  when 
pronouncing  an  opinion  upon  each  patient  during  an  epidemic. 

11.  In  the  writings  of  the  ancients,  particularly  in  those  of 
Hippocrates,  the  symptoms,  either  isolated  or  grouped  together, 
furnished,  in  themselves,  the  elements  of  prognosis.  At  this  day, 
when  the  diagnosis  of  diseases  has  acquired  a  degree  of  accuracy 
to  them  unknown,  the  importance  of  those  signs  furnished  by  the 
symptoms  has  doubtless  much  diminished  ;  but  it  is  still  of  suffi- 
cient power  to  make  it  impossible  for  the  physician  to  neglect 
noticing  these  signs,  when  forming  his  opinion  upon  the  ulterior 
course  of  a  disease. 

It  is  unnecessary  to  enumerate  here,  as  in  treatises  upon  semeiol- 
ogy,  the  unfavorable  or  favorable  signs  which  are  observed  in  the 
course  of  each  particular  disease :  we  shall  confine  ourselves  to 
the  presentation  of  those  which  may  be  exhibited  in  most  of  them, 
and  which,  for  this  reason,  belong  to  the  domain  of  general  pathol- 
ogy- 
External  appearance  furnishes  many  prognostic  signs  of  con- 
siderable importance.  Constant  change  of  position  awakens  no 
apprehension  at  the  commencement  of  acute  diseases ;  but  it  is 
otherwise  when  it  continues  for  many  days.  It  is  a  still  more  un- 
favorable sign,  when  the  patient  maintains  unceasingly  the  same 
position,  as,  for  example,  the  dorsal  decubitus,  as  is  seen  in  typhoid 
fever  of  adynamic  form ;  it  is  likewise  a  grave  sign  if  he  be  obliged 
to  remain  constantly  in  a  sitting  posture,  as  occurs  in  certain  tho- 
racic affections.  When  jactitation  succeeds  immobility  in  the  latter 
period  of  an  acute  affection,  it  is  generally  a  fatal  sign,  especially 
if  the  patient  uncover  himself,  and  if  he  make  unavailing  efforts 
to  rise.* 

The  progressive  loss  of  flesh  which  supervenes  in  acute  diseases, 
is  but  of  slight  importance,  but  in  chronic  diseases  we  should  ap- 
prehend from  it  a  fatal  termination,  which  is  nearer  at  hand  in 
proportion  as  the  marasmus  is  more  rapid.  The  oedematous  infil- 
tration which  is  manifested  during  the  course  of  chronic  diseases, 
is  likewise  a  most  unfavorable  sign.  This  is  not  the  case  in  re- 
spect to  partial  oedema,  confined  to  the  malleoii,  which  is  observed 
towards  the  close  of  acute  diseases,  and  is  connected  with  the  state 
of  prostration  and  languor  of  most  of  the  functions ;  this,  in  general, 
is  not  at  all  serious.  The  eschars  which  are  formed  in  different 


*  Among  other  prognostic  signs,  one  which  is  always  considered  grave,  may 
be  appropriately  added  to  those  here  mentioned,  viz.  the  sliding  down  in  bed, 
noticed  particularly  in  typhoid  fever  ;  the  patient's  lower  extremities  often  protrud- 
ing to  some  distance  from  the  foot  of  the  bed  ;  this  doubtless  arises  from  exces- 
sive debility,  and  although  the  state  in  which  it  is  observed  is  attended  with  more 
or  less  danger,  it  is  not  incompatible  with  recovery,  except,  indeed,  there  be  con- 
currence of  a  great  number  of  unfavorable  signs,  as  subsultus  tendinum,  coma, 
hiccough,  involuntary  evacuations,  rapid  and  fluttering  pulse,  labored  respiration, 
etc.  etc.  —  TRANS. 


PROGNOSIS.  349 

parts  of  the  body,  and  particularly  upon  those  where  the 
bones  are  near  the  integuments,  are  unfavorable  signs  in  chronic 
diseases:  they  are  also  nearly  always  so  in  acute  diseases,  and 
particularly  in  typhoid  fever  and  affections  of  the  spinal  chord ; 
not  only  because  their  appearance  adds  to  the  original  disease  a 
phenomenon  which  fully  reveals  its  gravity,  but  still  farther,  be- 
cause the  eschar  becomes  in  certain  cases,  when  the  primary  affec- 
tion has  disappeared,  a  source  of  debility  and  death  by  the  abun- 
dant suppuration  which  it  furnishes,  the  denudation  of  the  bones, 
the  purulent  absorption,  and,  in  certain  cases,  by  the  exposure  of 
the  rectum  in  the  pelvic  cavity. 

The  physiognomy  is  very  important  in  prognosis ;  but  it  ad- 
dresses itself,  if  we  may  so  express  ourselves,  only  to  the  practised 
eye.  "W  hen  the  natural  expression  is  preserved,  the  prognosis  is 
very  favorable.  A  remarkable  change  in  the  countenance,  from  the 
first  of  an  acute  disease,  should  lead  us  to  apprehend,  that  at  a  later 
period,  as  from  the  fifth  to  the  ninth  day,  adynamic  or  ataxic 
symptoms  may  supervene.  At  an  advanced  period  of  either  acute 
or  chronic  affections,  a  marked  and  sadden  alteration  of  the  coun- 
tenance announces  the  approach  of  death.  If  this  change  of 
countenance  take  place  at  a  time  when  death  seems  still  distant, 
we  should  suspect  the  development  of  some  acute  inflammation, 
which,  in  the  state  of  prostration  to  which  the  patient  is  reduced, 
most  frequently  does  not  give  rise  to  any  of  the  local  symptoms 
which  ordinarily  reveal  it,  and  only  determines  a  sudden  aggrava- 
tion of  the  general  condition.*  Those  in  whom  this  is  observed 
rarely  survive  more  than  three  days ;  most  frequently  they  die  in 
a  still  shorter  time.  —  The  rapid  increase  of  stature,  which  takes 
place  in  young  patients  during  acute  diseases,  is  also  a  sign  almost 
constantly  unfavorable. 

Tremor,  stiffness  and  subsultus  tendinum  always  indicate  dan- 
ger ;  picking  of  the  bedclothes,  and  particularly  epileptiform  or  te- 
tanic convulsions  and  rigidity  of  the  limbs,  are  usually  fatal  in  fever, 
when  they  supervene  at  an  advanced  period ;  convulsions  occur- 
ring at  the  commencement  of  diseases,  particularly  in  children  and 
in  the  eruptive  affections,  are  not  so  serious.  The  irregular  move- 
ments of  the  limbs,  which  the  patient  seeks  to  uncover,  although 
they  are  cold,  are  of  equal  value  with  convulsions  as  regards  prog- 
nosis ;  trismus.  the  sardonic  grin  and  strabismus,  are  of  like  signifi- 
cance. Another  sign,  still  more  unfavorable,  is  the  almost  auto- 
matic movement  by  which  the  patient  strives  unceasingly  to  bring 
his  arm  to  his  side,  while  the  physician  detains  it  outside  the  bed 
in  examining  the  pulse;  we  have  always  observed  these  cases  ter- 
minate fatally,  but  very  few  authors  have  mentioned  this  sign. 

Aphonia  is  one  of  the  most  unfavorable  signs  that  can  be  observed 
in  acute  diseases.  Many  of  the  patients,  however,  who  presented 

*  We  should  not  confound  this  change  of  countenance  with  pallor  of  the  face, 
which  denotes  the  cessation  of  the  fever  and  the  commencement  of  convalescence  ; 
the  two  differ  very  much  in  themselves  and  the  opposite  phenomena  which  ac- 
company them. 

30 


350  PROGNOSIS. 

this  symptom  in  the  epidemic  typhus  observed  at  Presburg,  in  J683, 
and  described  by  Lsew,  recovered.  We  have  seen  recovery  take 
place  in  patients  with  typhoid  fever,  who  had  been  aphonic  for 
many  days. 

Aphonia  supervening  during  a  chronic  affection  of  the  chest,  and 
persisting,  is  always  a  grave  sign,  because  it  leads  us  to  fear  the 
development  of  tubercles  in  the  larynx,  and  also  to  conclude  that 
they  exist  in  the  lungs. 

The  intensity  of  pain  in  disease  is  not  generally  in  proportion  to 
the  danger:  the  most  serious  diseases  are  not  usually  accompanied 
with  more  than  moderate  pain,  many  indeed  are  entirely  free  from 
it,  and  those  affections  in  which  pain  causes  cries,  as  hepatic,  ne- 
phritic and  lead  colic,  neuralgia,  rheumatism,  etc.  rarely  terminate 
unfavorably.  In  certain  chronic  affections,  however,  prolonged 
and  intense  pain,  preventing  sleep,  concurs  in  exhausting  the 
strength,  and  renders  the  prognosis  less  favorable,  independently 
of  the  disease. 

Other  things  being  equal,  deep-seated  pain  is  more  unfavorable 
than  that  which  is  superficial,  and  fixed  pain,  than  that  which  is 
moveable.  Very  severe  pains  in  the  limbs  at  the  commencement 
of  a  disease  indicate  its  future  severity ;  those  occurring  at  the  de- 
cline of  an  acute  affection  are  favorable.  In  the  phlegmasiae,  the 
sudden  cessation  of  pain,  joined  to  a  marked  change  of  the  counte- 
nance, indicates  the  approach  of  death ;  the  gangrene  announced 
by  most  authors,  is  rarely  discovered,  in  these  cases,  on  post-mor- 
tem examination  ;  the  inflamed  part  is  most  commonly  in  a  state 
of  suppuration,  as  all  those  physicians  who  make  frequent  dissec- 
tions must  be  convinced. 

The  various  disturbances  to  which  the  organs  of  sense  are  ex- 
posed, rarely  supply  us  with  prognostic  signs  of  much  importance 
in  regard  to  the  termination  of  the  disease ;  in  some  cases,  how- 
ever, they  are  the  forerunners  of  delirium,  coma,  or  some  other 
accident.  Most  authors  have  supposed  that  deafness  was  of  cer- 
tain value  as  respects  prognosis :  but  some  have  considered  it  a 
favorable,  others  an  unfavorable,  sign  ;  several  have  regarded  the 
deafness  occurring  towards  the  close  of  the  disease  as  favorable, 
and  that  noticed  at  the  commencement  as  unfavorable.  In  our 
opinion,  the  deafness  which  is  independent  of  any  material  lesion 
of  the  ear,  and  which  appears  as  a  sympathetic  phenomenon  in 
various  acute  diseases,  always  indicates  serious  danger  :  it  is  not 
observed  in  mild  diseases  ;  it  is  noticed  only  in  those  which  exhibit 
more  or  less  of  the  ataxic  character,  and  particularly  in  typhoid 
fever.  By  a  comparison  of  the  fatal  cases,  both  among  individuals 
who  had  been  affected  with  deafness  during  the  course  of  this  dis- 
ease, and  among  those  who  were  exempt,  we  have  been  led  to  the 
conclusion  that  in  the  former  the  mortality  has  been  nearly  double 
that  of  the  latter  class. 

The  mild  and  moderate  passions,  as  hope  and  gaiety,  are  gen- 
erally favorable  signs  in  disease.  The  depressing  passions,  on  the 
contrary,  as  hatred,  jealousy,  discouragement  and  despair,  are  of 
the  most  ominous  presage.  It  is  rare  that  patients  recover  from  an 


PROGNOSIS.  351 

acute  affection,  with  which  they  are  persuaded  they  shall  die,  un- 
less they  are  hypochondriacs ;  depression  is  then  not  so  unfavora- 
ble a  sign.  We  have  had  various  opportunities  of  being  convinced 
of  this,  particularly  in  the  case  of  a  young  man  of  melancholic 
temperament,  whom  we  attended  during  an  attack  of  typhus  fever. 
From  the  first  of  his  illness  he  had  arranged  his  affairs,  and  written 
a  very  pathetic  letter  to  his  father ;  the  apprehension  of  death  fol- 
lowed him  unceasingly  until  delirium  appeared.  During  this 
period,  when  asked  how  he  was,  he  promptly  replied  very  well, 
which  is  noted  by  Tissot  as  constantly  a  fatal  sign ;  the  disease, 
however,  terminated  favorably  on  the  fourteenth  day,  and  the  re- 
covery was  complete. 

We  should  not  mistake  for  safety,  either  the  affected  calm  of 
some  patients,  nor  that  prostration  of  the  intellectual  faculties 
which  deprives  the  individual  of  the  knowledge  of  his  situation, 
and  consequently  of  the  danger  which  threatens  him  ;  this  absolute 
indifference  is  a  grave  sign,  and  appertains  in  a  special  manner  to 
one  of  the  most  dangerous  forms  of  typhoid  fever.  A  certain 
degree  of  uneasiness,  in  proportion  to  the  gravity  of  the  disease,  is 
the  ordinary  condition  of  the  patient,  complete  security  is  unnat- 
ural, and  consequently  does  not  encourage  the  physician  ;  in  acute 
diseases  it  should  cause  him  to  fear  commencing  delirium;  in 
chronic  diseases,  and  especially  in  pulmonary  phthisis,  the  feeling 
of  security  in  the  patient  does  not  at  all  dimmish  the  gravity  of  the 
prognosis. 

The  prognostic  signs  furnished  by  delirium  are  subordinate  to  its 
intensity,  persistence,  and  the  conditions  in  which  it  appears.  Quiet 
and  transient  delirium,  which  consists  in  a  simple  wandering  from 
which  the  patient  may  be  easily  recalled,  is  not  very  serious; 
when  permanent,  especially  if  violent,  and  if  the  strait  waistcoat  be 
necessary,  it  is  always  a  bad  sign  ;  it  becomes  still  more  so,  if  the 
individual  be  advanced  in  years.  There  are,  however,  individuals 
even  among  adults,  who  are  delirious  during  the  course  of  almost 
all  the  diseases  with  which  they  are  affected,  even  in  ephemeral 
fever,  and  simple  angina ;  a  knowledge  of  this  idiosyncrasy  in 
patients  is  sufficient  for  the  appreciation  of  the  value  of  this 
symptom. 

Prolonged  sleep  need  cause  no  alarm  in  fevers  when  the  patients 
awake  easily  to  take  liquids,  and  answer  the  questions  addressed 
to  them  ;  but  when  it  becomes  necessary  to  shake  them,  or  to  shout 
aloud  in  order  to  wake  them,  the  prognosis  is  serious. 

When  the  sleep  is  not  quite  so  profound,  we  must,  according 
to  the  recommendation  of  Piquer*  regard  the  other  symptoms, 
in  order  to  judge  of  the  value  of  this  sign;  if  they  be  dangerous, 
the  sleep  is  so  likewise,  and  vice  versa. 

Prolonged  sleep  may,  in  certain  cases,  be  a  good  omen;  in 
the  delirium  which  succeeds  capital  surgical  operations  and  in 
delirium  tremens,  if  the  patients  sleep  calmly  for  a  certain  number 

*  Traite  des  Fievres}  p.  285. 


352  PROGNOSIS. 

of  hours,  on  awaking,  they  most  frequently  have  completely  re- 
covered their  intelligence,  and  do  not  remember  their  delirium. 
Coma  and  sopor  caroticus  are  very  grave  signs,  and  are  almost 
always  fatal  when  intense  and  continued.  There  is  more  hope 
when  they  take  place  at  the  commencement  of  disease,  in  cases, 
for  instance,  of  haemorrhage  or  concussion  of  the  brain,  than  when 
they  succeed  delirium  or  convulsions,  as  occurs  in  inflammations  of 
the  brain. 

Anorexia  is  not  at  all  unfavorable  in  acute,  any  more  than 
the  diminution  of  appetite  in  chronic  diseases ;  but  in  the  latter, 
disgust  at  food  is  a  bad  sign.  A  voracious  appetite,  which  super- 
venes suddenly  in  the  violent  stage  of  an  acute  or  even  a  chronic 
disease,  without  diminution  of  the  other  symptoms,  accordng  to 
Baglivi,  announces  death  in  tweniy-four  hours ;  we  have 
seen  death  succeed  this  irregular  hunger  almost  constantly,  as 
this  physician  has  remarked,  but  some  of  the  patients  lived  until 
the  second,  and  even  the  third  day.  Pneumonia,  in  our  ex- 
perience, has  furnished  the  most  instances  of  this  sign.* 

Slight  thirst  is  generally  a  phenomenon  of  little  value  in  a  prog- 
nostic point  of  view ;  but  extreme  thirst,  supervening  in  an  indi- 
vidual apparently  healthy,  always  arrests  the  attention  of  the 
physician  :  it  is  frequently  the  first  sign  of  commencing  diabetes, 
and  sometimes  of  pulmonary  phthisis.  We  shall  always  vividly 
remember  the  death  of  two  men,  in  mature  age,  with  this  latter 
disease,  both  remarkable  for  their  strong  constitution  and  embon- 
point, in  whom  the  same  phenomenon,  a  thirst  so  violent,  that 
every  evening,  for  nearly  a  year,  they  were  obliged  to  drink  one  or 
two  pints  of  water,  preceded  the  manifestation  of  tuberculous 
disease,  which  rapidly  destroyed  them. 

Observation  has  shown  the  exaggerated  importance  which  has 
been  attributed  to  the  different  modifications  presented  by  the 
tongue  in  disease,  in  reference  to  the  diagnosis  of  stomachal  and 
intestinal  affections;  it  has  confirmed,  on  the  other  hand,  the  value 
of  the  prognostic  signs  furnished  by  this  organ.  The  dryness, 
ligneous  hardness,  shrinking  and  tremulousness  of  the  tongue,  and 
the  difficulty  of  protruding  it,  are,  at  present,  as  in  the  days  of 
Hippocrates,  very  grave  signs,  and  indicate  great  danger.  The  va- 
rious coats  which,  in  the  forms  of  apthse,  pellicle  and  pulp,  cover 
the  mucous  membrane  of  the  mouth,  especially  when  they  consti- 
tute a  thick  layer,  and  become  renewed  immediately  after  they  are 
detached,  are  prognostic  signs  of  great  value  in  acute,  and  still 
more  so,  in  chronic,  diseases ;  in  the  latter  they  announce  a  termi- 
nation almost  inevitably  fatal,  in  the  former  they  increase  the 

*  This  has  also  been  noticed  in  the  last  stage  of  phthisis.  The  case  of  a  young 
man  in  this  stage  of  the  disease  recurs  strongly  to  our  recollection  at  this  time, 
whose  craving  for  food  was  so  irresistible  as  to  lead  him,  while  travelling  by  rail- 
way, to  snatch  from  the  hands  of  a  cliild  some  cake  it  was  eating,  much  to  the  as- 
tonishment of  his  fellow  passengers  ;  for  some  time  his  whole  attention  had  been 
directed  to  satifying  this  unnatural  appetite  :  this  individual,  however,  lived  for  a 
fortnight  after  the  above  occurrence,  making  the  voyage  from  England  to  this 
country,  and  dying  on  the  day  of  his  arrival  home.  —  TRANS. 


PROGNOSIS.  353 

gravity  of  the  prognosis,  without  being  so  constantly  the  indication 
of  an  unfavorable  termination. 

Difficult  deglutition,  but  more  particularly,  inability  to  swallow, 
are  signs  of  most  unfavorable  augury  in  cerebral  diseases  and  in 
those  acute  affections  in  which  the  examination  of  the  fauces  does 
not  show  the  cause  of  the  dysphagia.  —  Hydrophobia  or  horror  of 
liquids,  with  spasmodic  contraction  of  the  pharynx,  is  a  still  worse 
sign,  with  the  exception  of  those  cases  of  pregnancy,  hysteria  and 
inflammation  of  the  stomach,  in  which  this  phenomenon  has  fre- 
quently been  observed. — That  alteration  of  deglutition  in  which 
liquids  pass  through  the  oesophagus  as  through  an  inert  tube,  and 
fall  noisily  into  the  stomach,  has  for  a  long  time  been  noticed  as 
announcing  the  approach  of  death. 

The  continual  nausea  observed  in  certain  acute  diseases  is  a 
grave  sign;  it  is  frequently  the  prelude  of  that  obstinate  bilious 
vomiting  which  generally  resists  all  remedies,  and  finishes,  in  the 
greater  number  of  cases,  by  causing  death,  the  cadaveric  examina- 
tion not  always  accounting  for  the  intensity  of  the  symptom. 

In  the  last  stage  of  certain  diseases,  as  peritonitis  and  intestinal 
occlusion,  regurgitation  takes  the  place  of  vomiting;  death  is  then 
imminent. 

The  danger  arising  from  haematemesis,  and  stercoraceous,  puru- 
lent, or  rice-water  vomiting  (Asiatic  cholera),  is  subordinate  to 
the  intensity  and  persistence  of  the  symptom,  but  more  particularly 
to  the  kind  of  disease  which  causes  it.  Here,  as  in  all  cases,  the 
prognosis  is  in  a  great  degree  the  consequence  of  the  diagnosis. 

Meteorism,  when  considerable,  is  always  a  serious  sign,  both  in 
acute  diseases,  as  adynamic  fevers  and  the  various  forms  of  peri- 
tonitis and  in  chronic  diseases,  where  its  occurrence  should  lead 
us  to  fear  complete  occlusion  of  the  intestines  or  some  other  dan- 
gerous lesion. 

Constipation  does  not  become  a  serious  sign,  except  when  it 
resists  remedies,  arid  is  accompanied  with  vomiting,  as  in  the 
different  kinds  of  ileus,  a  complex  phenomenon,  which  always 
depends  upon  a  material  lesion  interrupting  the  course  of  the  faecal 
matter  through  the  intestines. 

Diarrhoea,  especially  when  it  resists  diet,  suitable  remedial 
means,  and  time,  and  when  the  discharges  are  both  numerous  and 
liquid,  is  a  grave  symptom,  both  in  acute  and  chronic  affections; 
it  leads  us  to  fear  the  existence  of  ulcerations  or  softening  of  the 
internal  tunic  of  the  intestine.  Obstinate  diarrhoea,  accompanied 
by  hectic  fever  and  morning  sweats,  is  nearly  always  a  fatal  sign  ; 
it  is  an  almost  certain  indication  of  a  tuberculous  affection,  even  in 
those  who  do  not  cough,  and  in  whom  the  various  modes  of  explor- 
ation of  the  chest  reveal  no  lesion  of  the  contained  organs.  A  black 
color  and  cadaverous  odor  of  the  faecal  matter  are  unfavorable 
signs.  Intestinal  haemorrhage,  supervening  in  the  course  of  an 
acute  disease,  is  a  grave  symptom,  observation  having  shown  that 
this  haemorrhage  hardly  ever  occurs  except  in  typhoid  fever,  and 
that  it  is  followed  by  death  in  at  least  one  half  of  the  cases. 
30* 


354  PROGNOSIS. 

Involuntary  evacuation  of  the  faeces  and  urine  is,  moreover,  a 
very  grave  sign  in  acute  diseases,  especially  when  the  patient  is 
unconscious  of  it ;  we  should  apprehend  from  this  symptom  the 
near  approach  of  death.  It  is  not  a  sign  of  equal  gravity  when 
the  intellectual  faculties  are  disordered;  but  even  then,  it  adds  to 
the  seriousness  of  the  prognosis. 

The  signs  furnished  by  the  respiration  should  be  ranked  among 
the  least  deceptive.  When  respiration  is  uniform,  free,  not  accel- 
erated, exempt  from  pain  and  oppression,  when  the  interval  be- 
tween inspiration  and  expiration  is  not  too  long,  and  the  patient 
respires  well  in  all  positions,  we  may  hope  for  a  favorable  termi- 
nation. On  the  contrary,  very  frequent  respiration  indicates  great 
danger ;  the  elevation  of  the  respiration  to  fifty  in  a  minute  is  a 
sign  nearly  always  fatal.  Stertorous  respiration  and  tracheal 
rattle  are  most  usually  the  phenomena  of  the  agony,  particularly 
when  they  supervene  in  the  latter  period  of  cerebral  diseases ; 
stertorous  respiration,  however,  is  not  so  grave  in  pulmonary  in- 
flammations when  expectoration  is  not  interrupted. 

"  Short  and  accelerated  respiration,  that  is,  respiration  made  up 
of  small  inspirations  and  expirations,  which  succeed  each  other 
rapidly,  is  a  very  bad  sign,  even  when  all  the  other  signs  seem 
favorable;"  "for  this  reason,"  says  Rtoll,  "whenever  I  do  not 
observe  this  sort  of  respiration  in  putrid  or  malignant  fevers,  and 
even  in  inflammations  of  the  thoracic  organs,  I  never  despair ;  but 
I  have  never  seen  any  patient  who  had  this  symptom,  recover."  * 

Embarrassed  respiration  occurring  in  paroxysms,  although  not 
without  gravity,  is  far  less  dangerous  than  permanent  dyspnoea. 
In  pulmonary  emphysema,  paroxysms  are  often  noticed  in  which 
the  oppression  almost  amounts  to  asphyxia,  and  nothing  is  more 
unusual  than  the  death  of  patients  during  these  paroxysms. 

Hiccough  is  a  very  unfavorable  sign  towards  the  close  of  dis- 
eases, when  unaccompanied  with  marked  amelioration  of  the 
symptoms. 

The  sputa  furnish  important  prognostic  signs.  In  peripneumo- 
nia,  when  they  are  serous,  red,  or  like  the  juice  of  liquorice  or 
prunes,  and  slightly  frothy,  the  disease  constantly  terminates 
fatally,  even  when,  in  other  respects,  it  seems  mild  in  its  character. 
In  phthisical  patients,  when  the  sputa,  from  having  been  a  long 
time  mingled  with  diffluent  mucus,  become  entirely  purulent,  or 
when  they  are  of  a  dirty  gray  color,  and  exhale  a  fetid  odor,  death 
is  generally  not  far  distant.  A  brown  color  and  gangrenous  odor 
of  the  sputa  announce  a  fatal  result. 

The  pulse,  considered  in  regard  to  prognosis,  supplies  us  with 
few,  but  important,  signs,  especially  in  acute  affections.  It  is 
always  encouraging  when  the  pulse  presents  a  moderate  frequency 
and  a  certain  degree  of  development  in  these  diseases.  Considera- 
ble frequency  of  the  pulse  constantly  denotes  a  serious  disease. 
If  the  pulse,  in  an  adult,  rise  to  one  hundred  and  fifty  pulsations 
in  a  minute,  and  more  especially,  if  beyond  that,  the  prognosis  is 

*  STOLL,  Rat.  Med.,  torn.  iii.  p.  62. 


PROGNOSIS.  355 

unfavorable  ;  *  if,  at  an  advanced  period,  the  pulse  become  irreg- 
ular, unequal,  intermittent  and  imperceptible,  death  is  imminent. 
Moderate  irregularity  of  the  pulse,  without  any  other  aggravation 
of  the  disease,  sometimes  precedes  and  announces  a  favorable 
change. 

Faintness  and  syncope  are  often  more  alarming  than  dangerous, 
especially  when  they  supervene  in  persons  who  are  not,  as  yet, 
much  debilitated ;  it  is  quite  otherwise,  when  they  occur  in  the 
opposite  conditions ;  they  should  then  cause  the  most  serious  and 
instant  anxiety. 

A  considerable  increase  of  heat  generally  denotes  a  grave  dis- 
ease, especially  when  the  heat  is  dry.  Coldness  of  the  extremities, 
extending  afterwards  to  the  rest  of  the  body,  supervening  during 
the  course  of  a  disease,  together  with  diminution  of  the  strength, 
and  aggravation  of  most  of  the  symptoms,  should  cause  apprehen- 
sion of  an  approaching  fatal  termination.  This  is  not  the  case 
with  that  coldness  which  takes  place  at  the  commencement  of  dis- 
ease, and  which  is  not  equally  grave,  although  in  some  of  its  forms 
(p.  346),  it  may  be  an  unfavorable  prognostic  sign.  The  irregular 
chills  which  supervene  at  an  advanced  period  of  the  disease, 
should  excite  suspicion,  either  of  the  formation  of  pus  in  inflam- 
matory affections,  or  of  its  absorption  when  there  already  exists  a 
purulent  collection,  as  after  extensive  injuries  and  particularly 
solutions  of  continuity. 

Suppression  of  the  cutaneous  exhalation,  which  is  known  by  the 
dryness  of  the  skin,  is,  generally,  if  not  a  dangerous,  at  least  an 
unfavorable  sign ;  suppleness  of  the  skin,  accompanied  by  a  gentle 
perspiration,  is,  on  the  contrary,  a  favorable  circumstance. 

Abundant  sweats  are  generally  injurious,  or  at  least  useless,  at 
the  commencement  of  diseases ;  they  are  often  favorable  at  their 
decline.  Continual  sweating,  in  the  course  of  an  acute  affection, 
often  produces  destructive  prostration,  as  was  observed  by  Cotugno 
in  the  hectic  fever  at  Naples.  The  cold  sweats  which  supervene 
at  the  decline  of  diseases  are  nearly  always  unfavorable ;  we 
have,  nevertheless,  seen  them  establish  a  favorable  crisis  in  a  child 

*  "  In  most  grave  diseases,  a  pulse  which  at  all  hours  exceeds  one  hundred  and 
twenty  indicates  serious  morbid  affection,  and  a  pulse  of  one  hundred  and  forty, 
if  long-continued  and  feeble,  is  indicative  of  danger."  —  (American  Editors  of 
Marshall  Hall's  Theory  and  Practice  of  Medicine,  p.  49.)  According  to  our  au- 
thor, also,  a  pulse  of  one  hundred  and  fifty  and  over,  in  the  minute,  renders  the 
prognosis  unfavorable  ;  we  remember  hearing  him  remark,  that  he  had  never 
known  a  patient  to  recover  who  presented  the  above  frequency  of  pulse,  for  any 
considerable  time,  in  acute  disease.  The  case  which  elicited  the  remark  was  one 
of  typhoid  fever,  where  the  pulse  was  so  rapid  that  it  could  not  be  counted;  death 
ensued  in  a  few  hours.  According  to  Dr.  Copland,  (prognostic  signs  furnished  by 
the  pulse  in  continued  fever,)  "  the  pulse,  to  the  experienced  physician,  furnishes 
the  chief  indications  of  danger,  as  well  as  of  treatment;  if  it  reach  one  hundred 
and  twenty,  the  danger  is  very  great,  if  it  amount  to  one  hundred  and  thirty, 
recovery  seldom  or  never  occurs,  unless  in  cases  of  hysterical  and  irritable  females, 
or  those  in  the  puerperal  state." — (Med.  Diet.  Am.  Ed.  p.  1135.)  Dr.  Graves 
has  remarked,  that  where  the  respirations  are  very  numerous  (forty,  for  example), 
with  a  comparatively  infrequent  pulse  (eighty  or  ninety),  a  fatal  result  may  gen- 
erally be  anticipated.  —  TRANS. 


356  PROGNOSIS. 

six  years  of  age,  on  the  seventh  day  of  very  grave  peripneumonia ; 
a  prompt  amelioration  of  the  local  and  general  symptoms  suc- 
ceeded the  cold  sweat,  by  which  the  parents  had  been  exceedingly 
alarmed. 

Haemorrhage  occurring  at  the  commencement  of  a  disease  gen- 
erally announces  its  future  severity;  that  which  supervenes  in  the 
last  period  is  rarely  indifferent;  it  is  most  commonly  followed  by 
a  marked  increase  or  diminution  in  the  pre-existent  symptoms. 
Epistaxis,  hsemorrhoidal  discharge  and  metrorrhagia,  are  gen- 
erally favorable  in  those  who  are  subject  to  them  during  health ; 
pulmonary  and  intestinal  haemorrhage  are  generally  unfavorable  ; 
that  from  the  urinary  passages  is  almost  constantly  fatal,  as  has 
been  observed  in  variola  (Sydenham),  in  the  plague  (Diemer- 
broeck),  and  also  in  yellow  fever. 

The  old  physicians  asserted  that  transparent  and  crude  urine 
indicated  a  lengthy  disease;  that  substances  remaining  suspended  in 
it  when  cool,  announced  the  termination  of  the  disease  at  a  period 
more  or  less  distant;  sedimentary  deposit,  an  approaching  termina- 
tion, etc.  There  is  nothing  certain  in  these  various  signs.  The 
involuntary  excretion  or  retention  of  urine  supervening  in  the 
course  of  febrile  affections,  or  in  those  of  the  medulla  spinalis  and 
the  brain,  most  frequently  indicate  great  danger. 

The  state  of  the  vital  forces  is  also  highly  important  in  prognosis. 
Every  affection  where  their  diminution  is  considerable  is  always 
very  dangerous;  their  perversion  is  equally  so. 

Certain  epi-phenomena  appearing  in  the  course  of  diseases, 
may  be  of  some  importance  in  prognosis  ;  the  parotiditis  noticed  in 
grave  fevers  and  in  typhus  is  particularly  of  this  class.  The 
development  of  the  parotids  in  acute  diseases,  has  been  regarded  as 
favorable  by  some  and  dangerous  by  others.  Hildenbrand  was 
led,  from  a  great  number  of  observations,  to  regard  inflammation 
of  the  parotids,  supervening  at  the  decline  of  disease,  as  favorable, 
and  that  occurring  at  the  commencement  as  unfavorable.  In  our 
opinion,  the  appearance  of  parotiditis  in  an  acute  disease  has 
always  a  gravity  which  increases  the  anxiety  the  disease  may 
already  have  inspired.  At  whatever  stage  of  the  disease  this 
swelling  occurs,  it  is  allowed  by  all  to  be  a  bad  omen  when 
it  attains  to  the  degree  of  embarrassing  deglutition,  and  above  all, 
respiration. 

The  aspect  of  wounds  and  of  surfaces  to  which  blisters  and 
rubefacients  have  been  applied,  supplies  us  also  with  prognostic 
signs.  When  wounds  are  of  a  bright  color,  and  furnish  thick  and 
homogeneous  pus,  it  is  a  favorable  sign;  the  contrary  is  the 
case  when  they  are  brown,  livid,  black,  dry,  or  pour  out  putrid  or 
sanious  matter.  It  is  a  very  unfavorable,  and  nearly  always  a 
fatal,  sign,*  when  blisters  and  sinapisms  produce  no  effect  upon 

*  It  often  happens  that  sinapisms  and  blisters  produce  no  effect,  even  in  patients 
who  are  not  dangerously  ill,  on  account  of  the  bad  quality  of  the  materials  em- 
ployed. It  is  important  to  be  on  one's  guard  against  the  false  inductions  which 
might  be  drawn  from  their  slight  action. 


NECROSCOPY.  357 

the  part  to  which  they  are  applied.  It  is  also  a  bad  sign  when  the 
dermis  peels  off  from  the  subjacent  parts  in  places  where  leeches 
have  been  applied  ;  we  have  constantly  observed  death  to  succeed 
this  sign,  seemingly  of  such  slight  importance. 

Such  are  the  principal  signs  by  whose  aid  we  are  enabled  to 
pronounce  an  opinion  upon  the  changes  which  will  supervene  in  the 
course  of  diseases.  These  signs,  we  repeat,  are  valueless,  except 
by  reason  of  the  reciprocal  support  they  yield  one  another.  A  single 
sign,  however  important  in  itself,  has  no  weight  except  by  the 
concurrence  of  many  others.  The  most  unfavorable  sign,  if  iso- 
lated, as  is  seen  in  certain  nervous  affections,  indicates  no  danger : 
convulsions,  picking  of  the  bedclothes,  general  insensibility,  horror 
of  liquids,  meteorism,  involuntary  excretions,  aphonia,  etc.,  are 
signs  of  almost  no  importance  in  hysterical  attacks,  and  almost 
always  fatal  in  febrile  affections.  It  is,  then,  only  by  a  comparison 
of  all  the  signs,  that  the  physician  can  obtain  a  knowledge  of 
future  events.  —  M. 


CHAPTER     XVIII. 

THE    ALTERATIONS    PRESENTED   BY   THE    ORGANS   AFTER   DEATH. 

THE  numerous  alterations  caused  by  disease,  in  the  structure  of 
our  organs,  have  of  late  years  greatly  attracted  the  attention  of 
physicians,  who  have  based  upon  them,  at  it  were,  a  new  sci- 
ence which  they  have  named  Pathological  Anatomy,  but  which 
ought  rather  to  be  considered  a  branch  of  pathology.  The  history 
of  diseases  is  necessarily  incomplete,  when  considered  indepen- 
dently of  the  structural  alterations  effected  by  them,  and  the 
study  of  these  alterations  is  almost  without  interest  when  discon- 
nected from  the  history  of  the  disease. 

We  are  surprised,  with  Senac,*  that  for  so  long  a  period  physi- 
cians showed  so  little  zeal  in  obtaining  the  light  that  necroscopy  f 
would  have  furnished  them  ;  but  it  is  still  more  astonishing  that  at 
the  time  when  the  anatomy  of  man  in  health  was  cultivated 
with  most  success,  the  lesions  which  disease  had  effected  in  his 
various  organs  should  have  scarcely  attracted  attention.  Fallo- 
pius,  Vesallus  and  Eustachius,  who  made  such  great  advances  in 
anatomy,  and  Harvey,  who  discovered  the  circulation  of  the  blood, 
lived  not  far  from  a  century  before  the  first  physicians  who  engaged 
in  the  study  of  pathological  anatomy.  The  example  of  Bartholin 
and  Theophilus  Bonet  was  followed  by  but  few,  as  Morgagni, 
Lieutaud  and  Portal^  and  it  was  not  until  the  end  of  the  last  cen- 

*  De  recondita  Febr  Natura,  pag.  194  ;  "  Mirum  est  sane  eos  qui  de  morbis 
scripserunt,  non  majori  studio  investigasse  quid  morleipsd  edeoceamur." 
t  NexQog,  dead  body  ;  oxo/recu,  I  examine. 


358  NECROSCOPY. 

tury  that  this  branch  of  pathology  was  generally  studied.  Since 
then,  all  educated  physicians  take  every  opportunity  to  ascertain 
after  death  the  nature  of  the  lesion  which  caused  or  accompanied 
the  phenomena  observed  during  life  ;  and  many  treatises  and  im- 
portant memoirs  have  been  published  upon  this  subject  by  the 
most  distinguished  physicians  of  our  age ;  among  whom  may  be 
mentioned,  Bayle,  Baillie,  Laennec,  Dupuytren ;  and  still  later, 
Brcschet,  Cruveilhier,  Louis,  Andral,  Bouillaud,  Rayer,  Carswell, 
&c.  &c. 

The  advantages  derived  from  the  study  of  pathological  anatomy 
are  now  so  generally  appreciated,  that  it  is  unnecessary  to  enu- 
merate them.  When  we  consider  the  numerous  errors  corrected 
by  post-mortem  examinations,  the  positive  information  they  furnish 
respecting  the  seat  of  many  diseases,  and  how  important  they 
always  are  in  confirming  or  rectifying  our  diagnosis,  it  cannot  be 
denied  that  these  investigations  have  greatly  conduced  to  the  ad- 
vance of  our  art,  and  must  still  continue  to  do  so  to  an  indefinite 
extent. 

In  order  to  discover  and  appreciate  the  lesion  produced  by  dis- 
ease, we  must  first  have  a  clear  idea  of  the  conformation  and 
structure  of  the  organ  in  health.  A  knowledge  therefore  of  nor- 
mal, should  precede  the  study  of  pathological  anatomy.* 

It  is  also  necessary  that  he  who  devotes  himself  to  these  re- 
searches, should  follow,  in  his  investigations,  some  convenient 
method,  that  nothing  essential  be  omitted,  and  that  the  examina- 
tion of  parts  first  exposed  may  not  interfere  with  that  of  others. 

Lastly,  it  is  very  useful,  if  not  indispensable,  to  have  a  previous 
knowledge,  from  accurate  descriptions,  or  rather  from  actual  obser- 
vation, of  the  various  alterations  to  which  the  organs  are  liable. 

ARTICLE    FIRST. 
Mode  of  Conducting  Post-mortem  Examinations. 

THE  terms  "  post-mortem  examination,"  "autopsy,"t  and  "  ne- 
cropsy, "J  are  synonymous,  and  express  both  the  operation  by  which 
the  internal  organs  of  a  dead  body  are  exposed  to  view,  and  the 
record  of  the  appearances  exhibited  by  them. 

$  I.  We  should  always  begin  the  examination  of  a  dead  body  by 
observing  its  external  aspect :  the  degree  of  fleshiness  or  emaciation 
should  be  noted  with  as  great  precision  as  possible.  The  general  or 
partial  tumescence  produced  by  air  or  serum  should  also  be  carefully 
ascertained.  It  is  sometimes  necessary,  particularly  in  examinations 
made  for  judicial  purposes,  to  observe  with  great  attention  the  atti- 

*It  is  desirable  that  the  varieties  of  form,  color,  consistence,  &c.  which  the 
organs  may  present  in  health  should  be  better  determined  and  more  accurately  de- 
scribed than  they  have  been,  hitherto,  in  order  that  we  may  distinguish  with  more 
precision  what  is  caused  by  disease,  and  what  is  only  a  variety  of  the  healthy  state. 

t  Avri)\iua  ;  from  uvro?,  himself;    and  onrouai,  1  see. 

t  Ntxqog,  dead  body  j  oTirojucu,  1  see. 


NECROSCOPY.  359 

tude  of  the  corpse  and  its  relation  to  surrounding  objects,  the  state 
of  the  clothes,  &c.  &c.     Circumstances,  apparently  very  trifling, 
may  become  important  in  the  further  development  of  facts.     The 
expression  of  the  countenance,  which  is  often  that  of  fear,  despair, 
&c.,  ought  not  to  be  neglected.     The  flaccidity  or  rigidity  of  the 
limbs  should  be  particularly  noted  ;  the  rigidity  always  commences 
with  the  jaws,  the  neck,  the  trunk,  afterwards  extending  to  the 
upper  extremities,  and  lastly  to  the  lower  ;  it  generally  comes  on  as 
soon  as  the  animal  heat  has  passed  off;  in  those  who  have  died  of 
an  acute  disease,  it  is  greater  and  more  durable  than  in  those  who 
have  died  of  a  chronic  affection;  wounds,  contusions,  ecchymoses, 
excoriations,    marks   of  ligatures,  eruptions,  tumors,   ulcerations, 
gangrene   of  the  integuments,    are  circumstances   which    should 
always  be  noted.     Attention  should  also  be  given  to  the  reddish  and 
livid  spots  caused  by  the  stagnation  of  the  blood  in  the  subcuta- 
neous cellular  tissue,  and  sometimes  in  the  skin  itself;  these  are 
generally  found  on  the  posterior  part  of  the  trunk  when  the  body 
has  lain  upon  the  back  since  death ;  they  may  exist,  however,  even 
upon  parts  of  the  body  which  have  not  been  dependent ;  but  in 
such  cases  they  are  almost  exclusively  found  in  the  neighborhood 
of  large  veins,  and  seem  to  be  caused  by  an  exudation  from  them. 
Sometimes  these  spots  are  diversified  with  lines,  furrows  and  marks, 
in  which  the  skin  still  remains  white ;  these  are  caused  by  the 
folds  of  clothing,  or  by  inequalities  on  the  surface  upon  which  the 
body  lies.     An  elevated  temperature  and  fluidity  of  the  blood  are 
conditions  which  favor  the  formation  of  these  spots.     They  are 
more  particularly  observed  in  persons  who  have  died  of  certain 
affections,  as  severe  fevers,  gangrenous  diseases,  variola,  scarlatina, 
&c.  &c.     Under  the  same  influences  the  epidermis  can  often  be 
detached  from  large  surfaces  by  the  slightest  friction.     It  is  impor- 
tant, especially  in  examinations  for  legal  purposes,  not  to  mistake 
post-mortem  lividity  for  ecchymoses,  which,  as  we  have  already 
shown,  are  symptoms,  and  are  caused  by  effused  or  infiltrated  blood. 
The  color  of  the  latter  varies  according  to  the  time  elapsed  since 
the  contusion,  and  with  the  degree  to  which  the  reabsorption  of  the 
blood  has  proceeded  ;  the  livid  spots  formed  after  death  are,  on  the 
contrary,  simply  owing  to  a  stagnation  of  the  blood  in  the  tissues. 
Marks  of  putrefaction  should  also  be  observed  ;  this  generally  ex  - 
hibits  itself  first  upon  the  abdomen  and  towards  the  iliac  fossa3,  in 
greenish  spots,  and  the  body  exhales  a  peculiarly  fetid  odor. 

§  II.  Having  examined  the  exterior  of  the  body  with  sufficient 
attention,  we  proceed  to  inspect  the  internal  organs.* 

Most  physicians  commence  the  examination  with  the  organ  of 
which  there  is  supposed  to  be  a  lesion ;  this  method  is  not  objec- 
tionable if,  after  having  found  the  suspected  lesion,  we  proceed  with 

*  The  instruments  necessary  in  the  examination  of  bodies  are  nearly  the  same 
with  those  employed  in  dissections,  viz.  scalpels,  knives,  blunt-pointed  scissors  of 
different  sizes,  an  enterotome,  a  rachitome,  several  probes,  a  saw,  and  a  hammer  ; 
a  glass  tube  is  sometimes  useful  for  inflating  organs,  in  order  to  render  certain  le- 
sions more  apparent. 


360  NECROSCOPY. 

the  examination  in  order  to  ascertain  whether  any  other  exists ; 
but  as  this  latter  is  often  neglected,  it  is  better  to  make  it  a  rule  to 
open  those  cavities,  first,  where  no  lesion  is  suspected. 

Where  there  is  no  reason  for  preference,  the  abdomen  should  be 
opened  before  the  chest,  and  the  latter  before  the  head,  because  by 
commencing  with  the  abdomen,  if  it  contain  fluid,  the  quantity 
and  nature  of  the  latter  can  be  more  readily  ascertained,  and  if 
there  be  any  fluid  in  the  thorax  it  is  prevented  from  escaping,  and 
the  depression  of  the  diaphragm  caused  by  it  can  be  readily  de- 
tected. In  commencing,  however,  with  the  thorax,  unless  care  is 
taken,  there  is  danger  of  slitting  down  the  diaphragm,  and  causing 
a  communication  between  the  pleura  and  peritoneum  ;  besides,  if  a 
liquid  fills  either  of  the  cavities,  a  portion  of  it  is  liable  to  escape 
into  the  other,  and  if  it  exists  in  both,  mixture  may  ensue,  and  in 
either  case,  error  or  great  uncertainty  results.  When  the  abdomen 
is  opened,  it  is  more  convenient  to  extend  the  incision  upwards 
and  open  the  thorax,  than  to  pass  to  the  examination  of  the  head 
and  return  to  the  chest,  more  particularly  as  after  opening  the 
head,  we  are  often  obliged  to  return  to  the  trunk  to  examine  the 
spinal  marrow. 

The  three  great  cavities  are  opened  in  the  following  manner. 
To  lay  bare  the  abdominal  viscera,  a  semicircular  incision  should 
be  made,  commencing  at  one  of  the  hypochondria,  descending 
towards  the  pubis,  skirting  the  anterior  and  superior  spines  of  the 
ilia,  and  terminating  at  the  other  hypochoridrium,  making  a  large 
flap  including  all  the  anterior  wall  of  the  abdomen.  When  this 
flap  is  turned  up  upon  the  thorax,  the  incisions  may  be  prolonged 
to  the  articulation  of  the  clavicles  with  the  sternum,  when  the 
chest  is  to  be  opened  by  dividing  the  cartilages  of  the  ribs ;  but 
when  the  latter  are  to  be  sawed  through,  or,  what  is  better,  divided 
by  a  costotome,  the  incision  should  be  carried  further  outward. 
When  the  ribs  and  clavicle  are  divided,  or  the  cartilages  cut 
through  and  the  sternum  disarticulated,  this  bone  should  be  re- 
moved from  the  mediastinum  by  means  of  a  scalpel,  turning  it 
upwards  towards  the  head,  and,  lastly,  should  be  entirely  detached 
together  with  the  flap.  In  some  cases,  in  order  to  more  fully 
expose  the  diseased  organs,  it  is  necessary  to  dislocate,  or  to  break 
the  ribs  near  their  posterior  extremity. 

In  opening  the  head,  we  commence  by  incising  the  integuments 
circularly,  carrying  the  incision  a  half  inch  above  the  eyebrows 
and  towards  the  superior  occipital  protuberance,  or  a  little  above 
it.*  This  incision  should  be  carried  completely  through  the  integ- 

*  A  more  simple,  and  certainly  much  less  objectionable  method  of  performing 
this  operation,  and  one  which  we  have  usually  seen  practised,  is  that  in  which  an 
incision  is  made,  extending  from  one  ear  to  the  other,  over  the  summit  of  the  head, 
the  edge  of  the  knife  being  turned  upwards  so  as  to  cut  from  within  outwards  ; 
the  flaps  are  then  dissected  back  far  enough  to  permit  a  horizontal  sweep  of  the 
saw,  in  a  direction  nearly  corresponding  to  that  recommended,  by  the  author,  for 
the  first  incision.  We  thus  avoid  the  unsightly  wound  which  must  follow  both 
the  methods  proposed  above.  —  TRANS. 


NECROSCOPY.  361 

uments,  and  the  way  for  the  saw  carefully  prepared.  A  crucial 
incision  may  also  be  used,  extending  it  from  the  root  of  the  nose  to 
the  occiput,  and  from  one  ear  to  the  other,  passing  over  the  crown  ; 
the  four  flaps  thus  found,  are  then  to  be  turned  back.  Having  in- 
cised the  integuments,  we  should  use  the  saw  to  divide  the  bone 
when  a  lesion  of  either  it  or  the  pericranium  is  suspected ;  in  other 
cases,  a  hatchet  or  hammer  made  for  the  purpose,  with  a  sharp 
edge,  is  more  convenient.  This  instrument,  it  is  true,  jars  the 
head  very  much,  but  it  does  not  tear  the  dura  mater  or  cerebral 
substance,  as  the  saw  is  liable  to  do ;  besides  which,  it  occupies 
Jess  time  than  the  latter.  When  the  bone  is  cut  through  all 
around,  a  hammer  or  chisel  may  be  inserted  into  the  anterior  part 
of  the  division  so  as  to  pry  it  open ;  the  fingers,  well  protected  by 
a  towel,  can  then  be  introduced  and  the  calvaria  torn  off,  leaving 
the  dura  mater  exposed. 

B.  In  the  succeeding  examination  of  the  parts  thus  uncovered, 
attention  should  first  be  given  to  the  external  condition  of  the 
viscera,  their  color,  form,  size  and  consistence,  their  relations  and 
accidental  adhesions,  and  to  the  fluids  in  the  visceral  cavities. 
They  may  be  then  pushed  aside  to  enable  us  to  examine  the  parts 
beneath,  and  turned  over  in  order  to  expose  their  other  surfaces, 
and  the  membranes  which  enclose  them  cut  through,  &c. 

Having  observed  with  sufficient  attention  the  exterior  conforma- 
tion of  the  viscera,  we  should  proceed  to  examine  any  internal  lesions 
they  may  present.  The  method  of  examining  the  hollow  organs, 
differs  from  that  employed  in  the  examination  of  others.  The 
first,  and  particularly  the  organs  of  respiration  and  digestion, 
ought  to  be  carefully  incised  as  soon  as  possible,  and  the  fluids 
they  contain  examined,  and,  if  necessary,  collected.  The  solid 
organs,  as  the  liver,  spleen,  brain  and  kidneys,  should  be  incised 
in  different  directions,  and  sometimes  cut  into  thin  slices,  or  shav- 
ings,— assulatim,  as  Morgagni  expresses  it;  the  ducts  should  be 
slit  open  and  their  lining  membrane  examined,  as  well  as  the  fluids 
contained  in  them.  A  very  delicate  dissection  is  sometimes 
necessary  in  order  to  appreciate  lesions,  and  no  pains  should  be 
spared  to  examine  them  thoroughly,  for  one  autopsy  badly  made, 
does  more  harm  than  good.  It  is  particularly  in  lesions  of  the 
nerves,  aneurismal  tumors,  considerable  alterations  of  the  structure 
of  certain  viscera,  and  chronic  inflammations  of  the  serous  mem- 
branes with  adhesions  of  the  viscera,  that  a  minute  examination 
is  often  indispensable. 

It  is  often  useful  to  inject  the  ducts  and  vessels  of  some  organs 
with  a  colored  and  coagulable  fluid,  whenever  it  is  desirable  to 
know  their  new  relations,  their  size,  or  the  obliteration  or  develop- 
ment of  a  collateral  circulation.  This  process  may  also  be  resorted 
to  in  cases  of  death  from  haemorrhage,  in  order  to  ascertain 
whether  the  blood  escaped  from  a  small  artery,  ruptured  or  ulcer- 
ated, or  by  simple  exhalation ;  as,  for  example,  in  the  hemoptysis 
of  tubercular  subjects. 

31 


362  NECROSCOPY. 

C.  Such  is  the  general  method  of  procedure  in  the  examina- 
tion of  the  different  viscera ;  in  making  a  further  inspection  of 
them,  the  following  method,  which  differs  from  that  recommended 
in  their  exposition,  is  to  be  preferred. 

We  should  commence  with  the  organs  of  circulation,  examining 
first  the  pericardium,  the  heart  and  the  large  vessels  which  leave 
or  empty  into  it.  The  heart  is  to  be  incised  longitudinally,  its 
color,  its  consistence,  the  thickness  of  the  walls,  from  the  base 
to  the  apex,  should  be  noted.  According  to  Bizot's  researches, 
the  thickness  of  the  walls  and  the  entire  volume  of  the  heart 
augment  progressively  from  infancy  to  old  age.  This  fact  is  an 
indispensable  element  in  our  means  of  appreciating  hypertrophy  at 
different  stages  of  life.*  The  fore  finger  should  be  passed  into  the 
different  orifices  of  the  heart  to  ascertain  whether  they  are  free. 
If  they  are  not,  they  should  be  exposed  to  view  by  an  incision,  in 
order  to  discover,  if  possible,  the  degree  and  cause  of  the  retraction. 
Before  however  doing  this,  we  should  ascertain,  by  pouring  water 
into  the  venticle  or  artery,  as  the  case  may  be,  whether  there  is 
inefficiency  of  the  valves,  that  is,  whether  they  be  so  affected  as 
to  permit  the  blood-vessels  to  regurgitate  through  them.  The  larger 
blood-vessels  of  the  chest  should  always  be  opened,  and  sometimes 
those  in  the  neighborhood.  They  are  generally  found  filled  to 
some  extent  with  fluid  and  clotted  blood,  their  walls  presenting, 
in  such  cases,  the  effect  only  of  imbibition,  a  red  color  which 
grows  brighter  upon  exposure  to  the  air. 

We  pass  next  to  the  organs  of  respiration.  Before  taking  the 
lungs  from  the  chest,  we  should  examine  whether  they  present 
marks  of  vesicular  or  interlobular  emphysema ;  squeeze  them  in 
order  to  ascertain  whether  they  are  soft  and  elastic  as  in  the 
healthy  state ;  and  incise  them  in  different  directions  to  ascertain 
their  structure.-)- 

When  tuberculous  excavations  or  purulent  cavities  exist,  we 

*  Bizot  has  furnished  in  his  paper,  exact  dimensions  of  the  walls  and  cavities 
of  the  heart  in  the  two  sexes,  and  at  different  ages. 

f  The  lungs  present,  upon  examination  after  death,  a  phenomenon  which  was 
long  since  observed,  but  not  correctly  explained.  Their  most  dependent  parts 
are  filled  with  fluid,  making  them  darker  and  heavier  than  the  others.  It  has 
been  supposed  that  this  engorgement  takes  place  immediately  after  death,  and  that 
consequently  we  can  tell  in  what  position  the  body  was  placed  at  that  moment. 
Bayle,  doubting  the  correctness  of  this  opinion,  made  some  experiments  to  ascer- 
tain the  fact.  He  recommended  that  persons  dying  upon  their  backs  should  be 
immediately  laid  upon  the  belly,  and  so  left  until  opening  the  body.  He  also  noted 
the  position  in  which  each  patient  lay  during  his  last  moments.  The  result  of 
these  examinations  was,  that  the  engorgement  of  the  lung  always  occurred  in  the 
part  dependent  just  before  death  ;  that  is,  in  the  back  in  the  greater  number,  at 
the  side  in  those  who  died  upon  the  side,  and  at  the  base,  in  those  who  had  retain- 
ed the  sitting  posture  during  the  last  hours  of  their  life.  Placing  the  corpse  upon 
the  belly,  produced  no  engorgement  in  the  anterior  part  of  the  lung.  These  ex- 
periments are  not  only  interesting  in  legal  medicine,  but  are  of  the  highest  impor- 
tance to  the  physiologist,  for  they  concur  m  demonstrating  the  influence  of  phys- 
ical laws  upon  man  in  disease  ;  an  influence  which  becomes  the  more  marked  as 
the  vital  powers  diminish. 


NECROSCOPY.  363 

should  examine  whether  they  communicate  with  the  pleura  or 
with  the  bronchia  ;  whether  they  are  in  the  pulmonary  parenchyma, 
or  in  that  portion  of  the  pleura  which  dips  between  the  lobes  of 
the  lungs  (interlobular  abscess).  The  communication  of  these 
cavities  with  the  bronchia,  may  be  most  readily  ascertained  by  in- 
flating the  lungs  through  the  trachea  by  means  of  a  glass  tube;  if 
the  abscess  have  existed  in  the  pleura,  the  cavity  of  the  chest 
should  be  filled  with  fluid,  into  which  the  bubbles  of  air  will  escape, 
and  thus  demonstrate  the  communication.  In  some  cases,  how- 
ever, they  can  be  discovered  by  a  simple  inspection  of  the  parts, 
or  by  slitting  open  tne  bronchia  by  means  of  a  director  and  bistoury 
or  probe-pointed  scissors.  In  examining  the  trachea  and  bronchia, 
they  should  be  slit  open  throughout  their  whole  extent,  in  order  to 
judge  of  the  modifications  they  may  present  as  to  their  dimen- 
sions (dilatation,  contraction,  obliteration),  the  color,  consistence 
and  thickness  of  the  parts  which  constitute  them,  and  of  the  secre- 
tions they  contain.  To  see  the  larynx  conveniently,  the  base  of 
the  tongue  must  be  separated  from  the  inferior  maxillary  bone  by  a 
semi-elliptical  incision  along  the  concave  surface  of  this  bone,  and 
prolonged  at  each  end  to  the  side  of  the  neck.  A  second  incision 
should  detach  the  volume  of  the  palate  and  the  posterior  walls  of  the 
pharynx  ;  then  drawing  out  the  tongue  and  larynx,  the  oesophagus 
and  trachea  should  be  cut  off  low  down  in  the  neck.  Having  sepa- 
rated the  mass,  the  pharynx  and  superior  part  of  the  oesophagus  are 
first  to  be  opened,  next  passing  to  the  examination  of  the  larynx, 
particularly  its  superior  entrance  and  the  glottis,  looking  through 
the  latter  to  ascertain  its  size,  and  then  slitting  it  open  to  inspect  the 
mucous  membrane  and  cartilages. 

Before  opening  the  larynx,  the  state  of  the  pharynx  should  be 
ascertained,  and  if  considered  desirable  the  oesophagus  may  be  slit 
down  throughout  the  whole  extent,  after  examining  the  organs  of 
respiration  and  circulation.  The  stomach  and  alimentary  canal  can 
then  be  opened  with  blunt-pointed  scissors,  or,  what  is  better, 
Cloquet's  enterotome.  This  is  important  to  ascertain  the  color  of 
the  mucous  membrane,  whether  it  is  injected,  and  if  the  injection 
is  uniform,  or  in  patches,  arborescences,  or  dots.  The  consistence 
may  be  ascertained  by  detaching  it  in  strips,  which  in  health  vary 
in  length  according  to  the  place  whence  they  are  torn.  At  the 
greater  cul  de  sac  of  the  stomach  they  are  three  or  four  lines  in 
length;  at  the  greater  curvature,  six  or  eight;  an  inch,  inch  and  a 
half,  and  sometimes  two  inches  at  the  lesser  curvature,  and  about 
the  pylorus  and  in  the  smaller  intestine,  from  five  to  ten  lines. 

The  thickness  of  the  mucous  membrane  and  the  state  of  the 
subjacent  tissues  should  be  attended  to ;  a  careful  examination 
should  also  be  made  of  Brumer's  and  Peyer's  glands,  which  pre- 
sent characteristic  alterations  in  typhoid  fever,  and  partake  of  the 
tubercular  degeneration  in  those  who  die  of  phthisis.  In  ascertain- 
ing the  state  of  the  mesenteric  glands,  their  relation  with  the  in- 
testine should  be  preserved,  to  enable  us  to  determine  if  the  lesions 
respecting  them  correspond  to  those  of  the  folds  of  the  intestines. 


364  NECROSCOPY. 

The  liver,  gall-bladder,  biliary  ducts,  spleen,  pancreas,  blood- 
vessels and  lymphatics,  where  these  exist,  are  to  be  taken  up  succes- 
sively, afterwards  the  urinary  organs,  beginning  with  the  kidneys 
arid  ureters,  and  ending  with  the  bladder  and  urethra  ;  closing  the 
examination  of  the  abdominal  viscera,  by  that  of  the  organs  of  gen- 
eration. 

The  brain  and  its  appendages  require  great  attention.  The 
dura  mater  should  never  be  incised  before  finishing  the  inspection 
of  the  thoracic  and  abdominal  cavities  ;  it  supports  the  brain,  and 
prevents  its  tearing.  It  is  even  preferable  not  to  open  the  cranial 
cavity  before  finishing  the  examination  of  the  chest  and  abdomen. 
The  dura  mater  should  be  divided  with  the  scissors,  or  scalpel, 
on  each  side  of  the  falx,  which  should  then  be  cut  across  near 
its  attachment  to  the  crista  galli  and  turned  backwards,  whilst  the 
dura  mater  thus  freed  may  be  pushed  outwards  from  off  the  hem- 
ispheres. Before  going  further,  the  cerebral  convolutions  must  be 
examined,  to  ascertain  whether  they  are  as  prominent  as  they 
should  be,  and  equally  so  on  both  sides.  When  the  flattening  is 
limited  to  one  hemisphere  we  ought  to  find  a  severe  lesion,  as  hae- 
morrhage, or  softening;  when  it  exists  in  both,  and  the  membranes 
are  not  inflamed,  it  is  owing  either  to  an  accumulation  of  serum  in 
the  ventricles,  or  to  a  hypertrophy  of  the  brain,  as  has  often  been 
noticed  in  persons  dying  of  cerebral  affections  produced  by  lead. 
In  opening  the  dura  mater,  notice  should  be  taken  of  the  quantity 
of  fluid  contained  in  it,  and  in  detaching  the  other  membranes,  their 
strength  as  well  as  the  degree  of  adhesion  to  the  cerebral  substance, 
should  be  ascertained.  It  is  generally  better  to  examine  the  brain 
in  situ,  a  rule  which  is  applicable  to  almost  all  the  viscera.  It 
should  be  cut  in  thin  slices,  especially,  when  approaching  the  lat- 
eral ventricles,  which  should  be  opened  very  carefully,  when  the 
brain  is  sliced  off  level  with  the  corpus  cullosum,  by  plunging  the 
point  of  a  scalpel  vertically  into  the  cerebral  substance,  three  or 
four  lines  from  the  median  line,  and  a  little  nearer  the  anterior 
than  the  posterior  surface  of  the  brain.  Those  cavities  should  be 
opened  throughout  their  whole  extent;  the  fornix  must  be  turned 
back  after  dividing  it  in  the  middle  so  as  to  display  the  third  ven- 
tricle. The  remainder  of  the  brain  is  to  be  cut  into  slices  as  far 
as  the  tuber  annulare.  The  tentorium  is  then  to  be  separated  from 
the  edge  of  the  temporal  bone  to  which  it  adheres,  and,  carrying 
the  point  of  the  scalpel  far  down  into  the  spinal  canal,  the  marrow 
is  to  be  divided,  and  the  cerebellum  removed.  After  taking  this 
organ  from  the  skull,  it  is  to  be  turned  over,  the  fourth  ventricle 
may  be  examined,  and  then  cut  into  slices  to  ascertain  whether  its 
substance  is  healthy.  The  examination  of  the  cranium  is  finished 
by  noting  the  vessels  that  ramify  over  the  inferior  wall  of  its  cav- 
ity, not  forgetting  to  open  the  sinuses  which  are  sometimes  inflamed 
or  obliterated. 

The  length  and  difficulty  of  the  preparations  necessary  for  lay- 
ing bare  the  spinal  marrow  without  injuring  its  tissue,  are  the  chief 
reasons  why  its  examination  is  so  often  neglected.  It  is  desirable, 


NECROSCOPY.  365 

in  most  cases,  however,  that  it  should  'be  carefully  made,  and  if 
done  with  perseverance  and  discernment  it  would  doubtless  lead 
to  interesting  results. 

Many  instruments  have  been  devised  for  the  double  object  of 
saving  trouble,  and  preventing  injury  to  this  organ  and  its  mem- 
branes. For  the  chisel  and  mallet,  which  were  originally  used,  a 
knife,  first  simple,  then  double,  with  a  convex  edge,  was  substi- 
tuted. To  this  was  next  added  lateral  guards  to  prevent  its  pene- 
trating too  deep  when  driven  by  a  hammer.  A  saw,  single,  or 
double,  with  a  convex  edge,  so  as  to  cut  the  processes  either  on  one 
or  on  both  sides  simultaneously,  was  next  proposed,  and,  lastly, 
Magendie  has  of  late  employed  large  scissors,  the  cutting  extremity 
of  which  is  very  short  and  curved,  so  as  to  pass  readily  into  the 
canal  whilst  the  other  extremity  being  long,  forms  a  powerful  lever 
with  which  the  bony  tissue  can  be  easily  severed.  These  various 
instruments  are  called  rachitomes. 

There  are  certain  diseases  in  which  we  ought  to  examine  the 
limbs,  as  in  wounds,  fractures,  abscess,  ulcers,  caries,  rheumatism, 
contraction,  dislocation,  phlebitis,  &c.  This  examination  requires 
no  special  rules. 

Such  is  the  most  convenient  method  of  making  post-mortem  ex- 
aminations :  *  it  can  and  ought  to  be  modified  by  circumstances,  a 
detail  of  which  would  be  here  out  of  place. 


ARTICLE  SECOND. 
The  principal  Lesions  presented  by  the  Organs  after  Death. 

WE  shall  now  proceed  briefly  to  consider  the  chief  lesions  which 
organs  present  after  death.  We  shall  class  them  in  three  princi- 
pal series,  viz..  1st,  lesions  of  solids;  2d,  alterations  in  the  fluids ; 
3d,  the  presence  of  foreign  bodies,  either  living  or  inanimate. 

1st  Series.  Lesions  of  Solids. — On  account  of  the  multitude 
of  subjects  which  these  comprise,  they  will  be  divided  into  three 
sections  ;  lesions  of  structure,  lesions  of  comformation,  and  lesions 
of  relation. 

§  1.  Lesions  of  Structure.  —  Among  the  lesions  of  structure, 

*  The  reader  may  be  surprised  at  our  advising  in  one  place  to  open  the  abdomen 
first,  and  in  another  to  examine  the  thoracic,  before  the  abdominal  viscera.  We 
have  already  stated  why  the  abdomen  should  be  first  opened,  and  the  following  are 
our  reasons  for  first  examining  the  thoracic  organs.  We  cannot  judge  well  of  the 
volume  and  distention  of  the  heart,  except  when  the  large  vessels  that  arise  from, 
and  empty  into  it,  are  intact.  If  we  commence  by  inspecting  the  abdomen,  and 
divide  the  liver,  the  vena  porta,  and  the  inferior  cava,  the  heart  will  collapse  be- 
fore we  examine  it.  For  the  same  reason  we  should  not  pass  to  the  lungs  before 
examining  the  heart.  The  oesophagus,  which  constitutes  part  of  the  digestive  ap- 
paratus, cannot  be  examined  until  after  the  heart  and  lungs,  behind  which  it  is 
situated,  be  removed,  which  is  another  reason  for  following  the  rule  we  have  laid 
down. 

31* 


366  NECROSCOPY. 

we  place  inflammations,  ulcers,  fistulge,  gangrene,  tubercles, 
cancer,  melanosis,  softening,  induration,  and  organic  transforma- 
tions. 

A.  Inflammation  does  not  uniformly  present  after  death,  the 
same  characteristics  in  the  different  tissues  in  which  it  is  situated, 
so  that,  in  some  cases,  it  is  even  more  difficult  to  point  out  its  effects 
in  the  dead  body,  than  to  specify  the  symptoms  which  indicated 
its  existence  in  the  living.  In  all  cases,  when,  upon  opening  the 
body,  a  part  is  found  more  voluminous,  redder  and  more  easily 
torn,  than  in  the  healthy  state,  we  have  reason  to  believe  that  it 
has  been  the  seat  of  inflammation  :  the  presence  of  pus,  either  col- 
lected or  disseminated  through  an  organ  ;  albuminous,  granulated 
membranous  or  tubulated  concretions,  are  sure  signs  of  inflamma- 
tion. It  does  not,  however,  always  show  itself  in  so  marked  a 
manner,  and  the  phenomena  which  characterize  it  must  be  studied 
in  each  tissue. 

In  the  mucous  membranes,  even  the  deepest  redness  is  insuffi- 
cient to  characterize  inflammation ;  *  in  order  to  this,  in  addition 
to  the  red  color,  there  must  be  an  alteration  of  consistence,  a  thick- 
ening, ulcerations,  or  a  creamy,  purulent,  or  brownish  exudation  : 
in  fact,  when  death  supervenes  very  speedily  after  the  inception 
of  inflammation,  the  only  traces  of  the  latter,  in  many  cases, 
are  an  injection  in  fine  points  or  in  patches,  and  readily  mistaken 
for  passive  or  post-mortem  injections.  The  latter,  however,  take 
place  in  dependent  parts,  being  often  noticed  in  the  folds  of  the 
intestines  which  dip  down  into  the  pelvis ;  they  are  accompanied 
by  an  injection  of  the  veins,  and  the  redness  they  produce  often 
disappear  by  washing  or  a  short  maceration,  whilst  the  redness  of 
inflammation  is  persistent.  The  same  test  has  been  used  to  dis- 
tinguish the  effect  of  inflammation  on  the  blood-vessels  from  the 
redness  of  imbibition. 

In  the  serous  membranes,  where  inflammation  neither  produces 
redness  nor  tumefaction,  the  presence  of  a  purulent  liquid,  of  false 
membranes  or  adhesions,  are  characteristics  which  do  not  permit 
us  to  doubt  its  existence,  provided  these  signs  are  constant.  But 
these  are  not  always  necessary ;  and  especially  in  cerebral  inflam- 
mations, in  which  a  slight  alteration  in  the  smoothness  of  the 
serous  surfaces,  a  pliability  somewhat  increased,  a  trifling  infiltra- 
tion of  the  cellular  membrane  which  unites  the  arachnoid  to  the 
cerebral  substance,  are  considered  by  most  physicians  as  signs 
sufficient  to  indicate  inflammation  of  this  membrane.  Lastly,  in 
some  cases,  the  simple  dryness  of  serous  membranes  in  those  who 
die  suddenly,  would  make  an  inflammation  of  short  duration,  the 
elfect  of  which  has  been  to  suspend  the  normal  secretion.  This 

*  In  persons  who  die  of  aneurism  of  the  heart,  the  mucous  membrane  of  the 
digestive  apparatus  usually  presents  a  blackish  red  color.  We  cannot  however 
allow  that  aneurism  of  the  heart  is  always  accompanied  by  inflammation  of  the 
mucous  membrane  of  the  stomach.  This  livid  redness  is  also  found  in  the  cheeks, 
lips,  hands,  without  there  being  any  other  indication  of  inflammation. 


NECROSCOPY.  367 

opinion,  first  put  forth  by  Marandel,  has  always  appeared  to  ns  haz- 
ardous, and  the  facts  observed  in  the  epidemic  Asiatic  cholera* 
which  ravaged  Europe,  give  increased  weight  to  the  doubts  which 
we  have  always  expressed  respecting  the  value  of  this  anatomical 
condition. 

In  the  cellular  or  laminous  tissue,  inflammation  shows  itself 
with  very  marked  characteristics ;  as  redness,  swelling,  hardness, 
and,  at  a  certain  period,  the  presence  of  pus  infiltrated  between  the 
layers  of  the  tissue  or  collected  in  a  cavity.  It  is  nearly  the  same 
with  the  lungs  where  it  occurs  under  various  forms,  but  with 
characteristics  generally  very  distinct  and  easily  perceived. \ 

This  is  not  however  the  case  with  the  brain,  liver,  spleen,  kidneys 
or  uterus,  particularly  in  women  who  die  a  few  hours  after  con- 
finement. In  all  these  organs,  if  we  except  those  cases  where  pus 
exists  in  the  parenchyma,  the  anatomical  signs  of  inflammation 
are  rather  obscure,  so  that  what  one  would  consider  indicative  of 
it,  another  would  regard  as  a  disease  of  a  totally  different  nature, 
while  a  third  would  look  upon  it  only  as  a  variety  of  the  normal 
condition.]; 

B.  Post-mortem  examinations  often  reveal,  in  the  interior  of 
organs,  ulcers,  the  existence  of  which  may  sometimes  be  recog- 
nized or  suspected  during  life,  but  whose  anatomical  disposition 
can  only  be  studied  after  death.  These  ulcers  are  sometimes  pri- 
mary or  simple,  that  is,  they  are  accompanied  by  no  other  altera- 
tion of  the  part  they  occupy.  But  in  most  cases  internal  ulcers 
are  the  consequence  of  the  softening  of  tubercles,  or  cancer;  or.  of 
the  separation  of  an  eschar,  or  of  a  specific  inflammation,  as 
syphilis.  An  internal  syphilitic  ulcer  presents  characters  analo- 
gous to  those  of  an  internal  one  in  the  living  subject ;  ulcers  from 
gangrene  or  from  tubercles,  generally  present  in  some  portions  of 

*  In  a  great  number  of  those  who  die  of  cholera,  the  serous  membranes  pre- 
sented a  remarkable  dryness. 

f  Inflammation  of  the  lungs  exhibits  itself  in  five  different  stages.  1st.  The 
"  engorgement  "  of  Bayle  or  the  "first  degree  "  of  Laennec,  in  which  the  lung  is 
heavier,  more  pliable  than  in  the  normal  state,  and  of  a  red  or  violet  color  ;  it  still 
crepitates,  but  less  than  in -health.  If  incised,  it  appears  gorged  with  a  frothy  and 
dirty  bloody  serum.  2d.  Red  hepatization  or  carnification,  in  which  the  lung 
is  easily  torn,  compact,  granulated,  red,  heavier  than  water  and  contains  no  air. 
3d.  Gray  hepatization,  in  which  the  lung  is  as  heavy  as  in  the  last,  does  not 
crepitate,  but  tears  still  more  readily,  and  is  permeated  with  a  gray  or  reddish 
purulent  fluid.  4th.  In  some  cases  the  lung  presents  all  the  characters  of  red 
hepatization,  except  the  hardness.  In  this  state  it  is  heavy,  contains  no  air,  and 
soft  like  the  spleen  ;  this  issplenization.  5th.  The  pulmonary  tissue  is  susceptible 
of  a  gray  induration  without  the  exhalation  of  pus  into  its  parenchyma  ;  in  this 
state,  which  seems  to  depend  upon  a  chronic  inflammation,  it  is  not  shining  and 
translucent  as  in  cancer,  and  no  puriform  liquid  escapes  from  it  when  torn,  as  in 
hepatization. 

J  Softening  of  the  cerebral  pulp,  cirrhosis,  the  granular  disease  of  Bright,  and 
the  engorgement  of  the  spleen  following  intermittent  fevers,  are  considered  as 
inflammations  by  some,  and  special  alterations  by  others.  In  the  numberless  mod- 
ifications in  color  and  consistence  of  the  liver,  who  can  exactly  make  the  bounds 
between  the  normal  and  diseased  state? 


368 


NECROSCOPY. 


their  surface  sloughs  or  tubercles,  which  indicate  their  nature ;  in 
cases  of  cancer,  an  incision  of  the  part  will  at  once  disclose  the 
kind  of  lesion  to  which  the  ulcer  belongs. 

The  existence,  in  the  small  intestines,  of  ulcers  more  or  less  nu- 
merous, furnishes  a  very  important  anatomical  character ;  of  all 
acute  dieases,  typhoid  fever  is  that  alone  in  which  this  is  an  almost 
constant  lesion,  and  among  chronic  diseases,  tubercular  affections 
are  those  in  which  it  is  almost  exclusively  noticed.  In  the  severest 
dysentery,  whilst  the  large  intestines  are  riddled  with  ulcerations,  the 
small  intestines  are  generally  exempt.  On  this  account,  whenever 
numerous  ulcerations  are  found  in  the  small  intestines,  we  should 
look  for  the  other  lesions  that  ought  to  accompany  them  ;  for  tuber- 
cle, if  the  patient  have  died  of  a  chronic  disease ;  for  typhoid  alter- 
ations, if  he  have  died  of  an  acute  one. 

C.  We  said  something  of  fistula  whilst  speaking  of  the  symp- 
toms furnished  by  the  internal  appearances  of  the  body;  we  will 
only  add  here,  that  they  can  only  be  thoroughly  studied  by  com- 
parison of  the  functional  disorders  that  they  produce  during  life, 
and  the  lesions  which  are  presented  after  death.     It  is  thus  only 
that  we  can  accurately  ascertain  their  direction,  orifices,  the  pecu- 
liarities of  the  structure  of  the  canal,   and,  sometimes,  even  the 
causes  which  have  kept  them  open. 

D.  Gangrene,  which  consists  in  the  death  of  some  part  of  the 
economy,  is  generally  indicated  by  very  marked  signs  which  nev- 
ertheless have  still  been  confounded,  in  post-mortem  examinations, 
with  black  discoloration ;  thus  there  is  often  some  question  as  to 
gangrene  of  the  pleura,  peritoneum  and  liver,  diseases  of  very  rare 
occurrence.     The  black  color  may  exist  without  gangrene,  and  the 
latter  may  exist  independently  of  the  other.     The  eschars  of  the 
mucous  membrane  are  often  of  a  grayish  or  whitish  color ;  those 
produced  by  nitric  acid  are  yellow ;   Quesnay  states  that,  in  one 
case,  he  saw  the  gangrened  parts  exhibit  a  remarkable  transpar- 
ence.    The  black  color  cannot  therefore  be  considered  as  charac- 
teristic of  gangrene.     Its  principal  characters  are;  1st.  complete 
disorganization    of  the   gangrened   part,  in   which  the  element- 
ary   tissues  can  no  longer  be  distinguished;    2d.     softness  and 
flaccidity  ;  3d.  the  fetid  and  characteristic  odor  which  it  exhales ; 
and  4th.  the  sanies,  ichor,   and  fetid  gas  which  escape  from  it. 
In  that  variety  of  gangrene  termed  dry,  the  part  presents  a  black 
color,    a  hardness  sometimes  like  that  of  wood,  and   always  a 
complete  disorganization  of  the  tissue.     Modern  surgeons  and  par- 
ticularly Richerand,  consider  necrosis  as  a  gangrene  of  the  bone. 

E.  Tubercles  exist  almost  always  in  large  numbers.  They  attack 
principally  the  lymphatic  glands,  the  viscera  lined  internally  with 
mucous  membrane,   and  more  especially  the  respiratory  organs. 
They  are  generally  developed  in  the  tissue  of  parts,  which  they, 
finally,  completely  pervade.     In  some  cases,  they  are  enveloped  in 


NECROSCOPY.  369 

a  membrane  (encysted  tubercles).  Their  size  varies  from  that  of  a 
millet  seed  to  that  of  an  orange  or  even  of  a  man's  fist.  Their 
aspect  and  anatomical  characters  differ  according  as  they  are  in  a 
state  of  crudity,  softening,  ulceration,  or  cicatrization,  so  that  unless 
they  have  been  traced  through  the  intermediate  stages,  what  are 
but  successive  phases  of  the  same  affection  might  be  taken  for  a 
disease  essentially  different.  Crude  tubercle  is  formed  of  a  whitish, 
yellowish,  or  grayish  opaque  and  solid  substance,  without  cohesion, 
resembling  soft  cheese,  and  in  which  no  vessels  or  other  appearance 
of  organization  can  be  distinguished.* 

In  softened  tubercle,  the  substance  has  lost  its  consistence ;  it  is 
liquid,  at  least  partly  so,  and  resembling  pus,  or  milk  mixed  with 
white,  opaque,  cheese-like  particles.  It  has  been  long  supposed, 
that  this  softening  takes  place  from  the  centre  towards  the  circum- 
ference; but  the  ingenious  researches  of  Mr.  Lombard,  of  Geneva, 
have  led  to  a  different  conclusion.  New  observations  are  required 
before  we  can  decide  upon  this  point.  Subcutaneous  tubercle 
opens  exteriorly  by  one  or  more  openings  often  fistulous  ;  internal 
tubercle  when  ulcerated,  opens  into  the  nearest  mucous  canal,  and 
soon  exhibits  sometimes  a  flattened  ulcer,  in  which  some  particles 
of  unsoftened  tuberculous  matter,  (tuberculous  ulcer  of  the  intes- 
tines, larynx,  fc.)  and  sometimes,  as  in  the  pulmonary  parenchyma, 
a  cavity  of  greater  or  less  size,  often  irregular  and  sinuous,  in 
which  a  purulent  matter  is  alone  discoverable.  In  some  cases, 
there  only  exists  in  the  place  of  these  excavations  a  sort  of  fibro- 
cartilaginous  mass,  near  which  the  surface  of  the  lung  is  shrivelled, 
and  which  presents  in  its  centre  traces  of  a  cavity  with  which  one 
or  more  of  the  bronchi  communicate. 

The  chalky  concretions  which  are  frequently  met  with  at  Ine 
summit  of  the  lungs,  especially  in  old  persons,  are  attributed  to  tu- 
bercular disease,  being  considered  as  a  transformation  of  the  tuber- 
cle, and  one  of  the  modes  of  a  favorable  termination  of  the  affection. 
This  proposition,  which  has  numerous  partisans,  and  which  is  not 
without  plausibility,  does  not  yet  appear  to  us  sufficiently  demon- 
strated. 

F.  Granulations  are  small  globular  bodies,  transparent,  smooth, 
elastic,  sometimes  marked  by  lines  or  black  points,  and  somewhat 
analogous  to  cartilage  in  appearance.  This  lesion,  which  has 
been  particularly  described  by  Bayle,  has  been  considered  by  La- 
ennec  as  the  first  degree  or  rudimentary  state  of  tubercle,  arid  this 
last  opinion,  adopted  by  most  writers  of  the  present  day,  is  now 
generally  admitted  to  be  correct.  We  do  not,  however,  submit  to 
the  general  conviction.  We  acknowledge  that  where  the  lung  is 
pervaded  by  granulations  it  is  not  unusual  to  detect,  in  the  centre 
of  some  of  them,  a  small  point  of  opaque  matter  analogous  to  tuber- 

*  Chemical  analysis  gives  96  15  parts  of  animal  matter,  and  some  hundred! hs  of 
hydrochlorate  of  soda,  of  phosphate  and  carbonate  of  lime,  with  a  slight  trace  of 
oxide  of  iron. 


370  NECROSCOPY. 

cle;  we  acknowledge  also  that,  generally,  tubercles  and  granula- 
tions are  found  in  the  same  subject ;  but  we  do  not  think  these 
circumstances  sufficient  to  demonstrate  with  certainty  the  connec- 
tion between  the  two  affections,  any  more  than  we  should  conclude, 
from  the  tubercular  matter  in  cancerous  masses  of  the  liver,  that 
cancer  and  tubercle  are  two  alterations  of  the  same  nature.* 

G.  Cancer  exhibits  itself  under  the  different  forms  of  schirrus, 
encephaloid  disease,  and  cancerous  ulceration.  The  characteristics 
common  to  these  lesions  are  indefinite  increase,  whatever  be  their 
form  (degeneration,  or  ulceration)  ;  an  almost  constant  reproduc- 
tion after  excision  or  destruction  ;  a  complete  incurability  when 
abandoned  to  themselves,  their  general  phenomena  being  progres- 
sive wasting ;  and  alteration  in  the  color  of  the  skin,  more  particu- 
larly of  that  of  the  face,  which  assumes  a  straw  or  sodden  yellow. 

Schirrus  consists  of  a  hard,  grayish,  or  bluish  white  tissue,  mak- 
ing a  peculiar  noise  when  cut.  This  tissue  is  not  completely  ho- 
mogeneous, but  there  may  be  distinguished  in  it  a  texture  formed  of 
fibrous  laminae,  in  which  is  contained  a  matter  resembling,  in  color 
and  consistence,  the  skin  of  bacon.  In  other  cases,  these  laminae  are 
arranged  in  radii,  the  cut  surface  of  the  cancer  presenting  an  ap- 
pearance analogous  to  that  of  a  turnip ;  it  is  this  form  that  some 
writers  have  termed  napiform.  By  compressing  the  schirrus,  we 
can  generally  force  out  a  transparent,  albuminous  fluid,  which 
some  persons  have  designated  under  the  name  of  cancerous  fluid. 
The  injections  made  by  Scarpa  have  led  to  the  conclusion  that 
schirrus  does  not  contain  arteries  or  veins,  or  at  least  only  a  few 
ramusculi. 

Encephaloid  or  cerebriform  cancer  is  an  accidental  production,  or 
organic  degeneration  of  a  milky  white  color,  slightly  tinted  with 
pink,  exhibiting  often  the  color  and  consistence  of  cerebral  pulp, 
and  sometimes  pervaded  by  effused  blood  collected  in  cavities  of 
greater  or  less  size.  M.  Berard  has  demonstrated  by  injections  and 
dissections  f  that,  on  the  one  hand,  the  encephaloid  tissue  is  pene- 
trated by  a  great  number  of  arterial  vessels,  the  number  and  size 
of  which  increase  as  the  softening  becomes  more  considerable  ;  and, 
on  the  other,  that  there  are  no  permeable  veins  in  the  centre  of  en- 
cephaloid masses,  whilst  the  periphery  of  these  tumors  consist  of  a 
highly  developed  venous  network.  This  development  of  the  arte- 
ries and  atrophy  of  the  veins  satisfactorily  explain  the  haemor- 
rhages, to  which  parts  affected  with  this  kind  of  cancer  are  subject. 

Encephaloid  matter,  like  tubercle,  attacks  all  organs ;  the  bones 
themselves  are  very  frequently  affected.  It  sometimes  exists  in  a 
state  of  infiltration,  but  is  most  often  found  in  layers  or  smaller 
masses,  and,  sometimes,  encysted.  In  some  organs,  as  the  lungs, 
and  more  especially  the  liver,  this  matter  is  deposited  in  roundish 

*  See  our  article  "Granulations"  in  the  Dictionnaire  de  Medecine   of  21  vols. 
vol.  x. 

|  Dictionnaire  de  Med.  in  21  vols.,  Art.  Cancer. 


NECROSCOPY.  37 L 

masses,  of  the  size  of  a  filbert,  walnut,  or  a  hen's  egg,  which  seem 
to  be  developed  in  the  interstices  of  the  parenchyma,  which  they 
separate  and  compress  without  affecting.  They  adhere  but  slightly 
to  the  neighboring  part  and  are  easily  enucleated.  The  soft  vege- 
tations which  are  developed  upon  some  points  of  the  mucous 
membranes  are  generally  encephaloid  cancer. 

Cancer  shows  itself  upon  the  lips  and  the  os  tincse,  particularly 
under  the  form  of  a  simple  ulceration,  without  the  existence  of 
schirhus  or  encephaloid  matter  beneath  it,  and  which  nevertheless 
resembles  cancer  in  the  firmness  which  is  felt  in  it  when  pressed 
by  the  finger,  and  in  the  lancinating  pain  and  general  phenomena 
which  accompany  it.  This  is  a  form  of  cancer  which  commences 
where  the  others  finish,  and  in  which  the  ulceration  seems  to  destroy 
the  cancerous  tissue  as  soon  as  it  is  formed. 

There  is  an  affection  characterized  by  the  development  of  a  whit- 
ish transparent  matter  resembling  jcalf  s  foot  jelly,  which  has  been 
considered  a  species  of  cancer,  and  to  which  the  term  colloid  or 
gelatiniform  has  been  applied.  It  is  most  often  found  in  the  ovaries. 
This  morbid  production  appears  to  us  to  be  a  development  sui 
generis,  and  to  be  too  distinct  from  schirrhus,  encephaloid  or  ul- 
cerated cancer,  to  be  confounded  with  them  under  the  same  name. 

H.  Melanosis  *  is  an  alteration  of  tissue  which  some  authors 
have  considered  as  a  variety  of  cancer,  and  to  which  they 
have  applied  the  term  melanotic.  It  shows  itself  in  rounded 
or  irregular  masses,  of  firm  consistence,  of  a  black,  purple  or  bluish 
color,  and  size  varying  from  that  of  a  pea  to  that  of  the  fist,  and 
presenting,  in  its  consistence,  form  and  color,  some  resemblance  to  a 
truffle.  Some  physicians  have  thought  that  the  melanotic  tissue 
is  capable  of  being  softened  and  ulcerating  (Bayle  and  Laennec), 
but  there  is  no  agreement  upon  this  point.  This  is,  in  our  opinion, 
melanosis,  properly  so  called,  and  that  to  which  the  name  ought 
alone  to  be  given.  It  should  not  be  confounded  with  the  black  color 
often  presented  by  the  glands  surrounding  the  roots  of  the  lungs 
and  larger  divisions  of  the  bronchia,  possibly  produced  solely  by 
age.  Nor  do  we,  with  MM.  Breschet  and  Casenave,  consider  the 
blackish  and  pitchy  matter  which  is  met  with,  or  the  surface  of 
mucous  membranes,  thrown  off  in  melena,  and  more  rarely  excret- 
ed with  the  urine,  as  a  variety  of  melanosis  (liquid  melanosis). 
In  our  opinion,  although  chemical  analysis  may  demonstrate  the  ex- 
istence of  similar  elements  f  in  melanotic  masses  and  in  the  black 
liquids  which  have  been  associated  with  melanosis,  although  there 
may  be  between  them  as  great  an  analogy  as  between  cancer  and 
the  sanies  which  flows  from  its  ulcerated  surface,  we  think  that 
a  complete  degeneration  of  tissues  and  a  morbid  secretion  should 
not  be  confounded  under  a  common  name,  especially  when  obser- 
vation exhibits,  on  the  one  hand,  melanotic  masses  without  any 

*  MtZag,  black  ;  voaog,  a  disease." 

|  Many  chemists,  particularly  MM.  Thenard,  Barruel  and  Lassaigne,  have 
detected  in  melanosis,  as  in  the  black  matter  thrown  from  the  stomach,  most  of 
the  elements  of  the  blood. 


372  NECROSCOPY. 

traces  of  liquid  melanosis,  and  on  the  other,  the  so  called  liquid 
melanosis,  without  the  existence  of  the  former ;  the  secretion  of 
black  matters,  never  in  fact  proceeds  from  a  melanotic  degeneration, 
but  is  generally  produced  by  cancerous  ulceration. 

The  other  alterations  of  structure,  of  which  we  are  now  about 
to  speak,  have  this  in  common ;  that  they  all  resemble  some  one 
of  the  tissues  of  the  animal  economy  in  a  healthy  state.  On  this 
account  they  are  called,  in  general,  transformations,  each  being 
designated  by  a  particular  epithet.  The  principal  of  these  are  the 
cutaneous,  mucous,  serous,  fatty,  fibrous,  bony,  cartilaginous  and 
horny. 

I.  The  cutaneous  transformation  is  often  observed  in  mucous 
membranes,  where,  in  consequence  of  a  prolapsus  of  the  organs 
which  they  invest,  they  become,  as  it  were,  external  organs.  This 
takes  place  in  prolapsus  of  the  .vagina,  of  the  uterus  and  rectum. 

J.  The  like  is  observed  in  the  mucous  transformation  which  is 
met  with  in  fistulous  tubes  communicating  with  a  cavity  lined  by 
mucous  membrane.  The  cellular  tissue  changes  progressively  its 
nature,  and  takes  the  character,  throughout  the  whole  length  of  the 
fistula  of  a  mucous  membrane,  in  which,  however,  there  are  no 
villi  or  follicles. 

K.  Serous  transformation  is  one  of  the  most  frequent.  It  oc- 
curs in  almost  every  instance  where  a  foreign  body  remains  for  a 
long  time  in  any  part  of  the  animal  economy,  particularly  in  the 
cellular  tissue,  the  organization  of  which  peculiarly  resembles  that 
of  the  serous  membranes.  An  accidental  serous  membrane,  con- 
stituting, like  all  serous  membranes,  a  sac  without  an  opening,  may 
be  found  around  collections  of  pus ;  apoplectic  clots,  heads  of  dis- 
located bones  and  foreign  bodies,  such  as  missiles  engaged  in  the 
tissues;  it  is  also  an  accidental  serous  tissue,  to  which  the  hydatids 
attach  themselves  in  the  disease,  known  by  the  name  of  ovarian 
dropsy. 

L.  Fatty  transformation  has  been  observed  in  various  organs, 
as  the  heart,  muscles,  mammae  and  pancreas.  It  is  very  frequent 
in  the  liver,  where  it  can  be  recognised  by  the  whitish  appearance, 
unctuous  feel  and  fatty  streaks  displayed  by  incising  it,  and  still 
more  by  the  grease  spot  which  it  gives  to  paper  when  exposed  to 
the  action  of  heat.  Authors  are  not  agreed  as  to  the  manner  in 
which  the  transformation  is  effected;  some,  among  whom  is  Ari- 
dral,  think  it  is  produced  by  a  too  profuse  secretion  of  fat  in  the 
tissue  which  ordinarily  secretes  it,  whilst  the  neighboring  parts  are 
compressed  and  atrophied  without  undergoing  transformation, 
properly  so  called.  Others,  on  the  contrary,  suppose  that  the  tis- 
sue itself  of  the  organs  undergoes  an  alteration,  and  becomes 
changed  into  fat ;  fatty  degeneration  of  the  liver,  which  in  health 
contains  no  adipose  cells,  may  be  adduced  in  support  of  the  latter 
opinion. 


NECROSCOPY.  373 

M.  Fibrous  degeneration  generally  occurs  in  certain  cysts,  in 
various  tumors,  and  more  particularly  in  those  of  the  ovaries. 

N.  Ossification  is  an  alteration  which  frequently  occurs  in  old 
persons,  but  which  has  been  also  sometimes  observed  before  adult 
age.  It  is  met  with  in  the  valves  of  the  heart,  in  the  arteries, 
muscles,  serous  membranes,  cysts,  ligaments  and  cartilages.  Pe- 
trifactions have  often  been  confounded  with  ossifications,  properly 
so  called.  Morgagni  pointed  out  the  laminated  or  fibrous  tissue  of 
the  bone,  as  the  most  proper  means  for  distinguishing  those  lesions. 
Chemical  analysis  furnishes  a  more  ready  and  sure  means  of  diag- 
nosis; the  osseous  tissue  consisting  essentially  of  phosphate  of 
lime  and  gelatine,  whilst  petrifactions  may  present  a  totally  differ- 
ent composition. 

O.  Cartilaginous  degeneration  is  generally  but  the  first  degree 
of  the  osseous. 

P.  The  corneous  transformation  has  only  been  observed  in  the 
skin. 

$  II.  We  shall  include  in  this  section,  all  the  modifications 
presented  by  the  external  aspect  of  organs,  as  we  have,  in  the  first, 
considered  all  those  presented  by  their  internal  organization. 

With  these  modifications,  are  connected  those  of  form,  volume 
and  color.  We  shall  confine  ourselves  to  their  enumeration. 

A.  Among  alterations  of  form,  may  be  mentioned:  1.  Solu- 
tion of  continuity  in  the  hard  or  soft  parts  (from  wounds,  ruptures 
from  internal  or  external  causes,  fractures,  separation  of  the  carti- 
lages and   epiphyses).     2.  Vices   of   conformation    which  some- 
times can  only  be  suspected  during  life,   and  which  can  almost 
always  be  better  appreciated  after  death.    3.   Excrescences  of  all 
kinds  which  are  developed  either  upon  the  skin  or  the  mucous 
membranes,  vesicular  or  hard  polypi,  bridles,  &c.     4.  Knots  and 
other  inequalities  which  the  surface  of  the  viscera  often  presents, 
as  in  cirrhosis  or  in  cancer  of  the  liver,  nodes  in  syphilis.     5.  Flat- 
tening of  the  inequalities  peculiar  to  certain  organs,  to  the  brain  for 
instance. 

B.  Under  alterations  of  volume,  may  be  mentioned:  1.  Disten- 
sion of  the  hollow  viscera,  and  the  approximation  of  their  walls. 
2.  The  enlargement  or  retraction  of  tubes  in  general,  and  of  their 
orifices  in  particular.     3.  The  augmentation  or  diminution  of  some 
of  the  solid  organs,  as  the  brain  and  muscles. 

C.  Among  alterations  of  co/or,  we  class  the  livid  rubefaction  of 
all  the  tissues  in  the  bodies  of  those  who  have  died  asphyxiated ; 
the  yellow  color  in  jaundice,  the  red  or  blackish  spots  in  scurvy 
and  certain  cases  of  poisoning,  the  non-inflammatory  redness  of 

32 


374  NECROSCOPY. 

mucous  membranes,  that  of  the  choroid  membrane  of  the  iris  and 
of  the  internal  tunics  of  the  vessels,  the  pale  or  deepened  color  of 
the  muscles,  the  black  or  pale  yellow  color  of  the  liver,  the  mottled 
appearance  of  the  spleen,  &c.  &c. 

2d  Series.  Alterations  of  the  Fluids.  — Some  of  the  alterations 
which  the  fluids  undergo  are  appreciable  during  life,  and  have  al- 
ready been  considered  in  the  chapter  devoted  to  symptoms.  We  will 
here  only  notice  those  alterations  which  are  alone  detected  or  made 
more  apparent  by  necroscopy.  We  shall  first  briefly  examine  the 
alterations  of  the  liquid,  afterwards  those  of  the  gaseous  fluids. 

$  I.  Alterations  of  the  Liquids.  —  We  shall  first  consider  the 
liquids  of  the  circulation,  as  the  blood  and  lymph,  and  afterwards 
the  exhaled  or  secreted  fluids. 

A.  We  have  above  (pp.  182  to  189)  detailed  the  principal  al- 
terations exhibited  by  the  blood  during  life,  escaping  externally, 
either  in  cases  of  haemorrhage  or  by  an  artificial  orifice  in  the  arte- 
ries or  veins.  We  have  here  but  to  discuss  those  which  are  revealed 
by  post-mortem  examinations. 

The  blood  drawn  from  a  vein  at  the  commencement  of  typhoid 
fever  generally  presents  no  notable  alteration,  except  a  slight  dimi- 
nution in  the  consistence  of  the  clot,  a  phenomenon  by  no  means 
constant.  But  if  the  patient  die  at  a  period  when  venesection 
is  no  longer  practicable,  the  blood  is  found  sometimes  fluid,  but, 
more  often,  united  in  black  clots,  which  are  soft  and  friable,  and 
consequently  very  different  from  the  fibrinous  and  dense  coagula 
which  are  found  in  the  vessels,  and  particularly  in  the  heart,  of 
most  of  those  who  die  of  other  acute  diseases. 

In  some  patients,  who  die  with  symptoms  of  purulent  absorp- 
tion, adherent  or  free  clots  filled  with  pus  are  found  in  the  vessels 
and  heart.  In  other  cases,  pus  has  been  found  collected  in  a  single 
cavity  in  the  centre  of  a  clot,  which  becomes  thus  transformed,  as 
it  were,  into  an  abscess. 

There  is  another  alteration  of  the  blood  which  necroscopy  can 
alone  reveal.  This  is  the  presence  of  encephaloid  matter  in  the 
veins  near  a  cancerous  mass.  Velpeau.  who  published  one  of  the 
first  of  several  curious  observations  upon  this  subject,*  supposes  that 
the  blood  coagulating  in  the  vessels  becomes  converted  into  ence- 
phaloid matter.  It  is  the  opinion  of  others,  that  in  these  cases 
cancerous  matter  is  absorbed  by  the  veins,  and  that  by  it  the  fibrin e 
of  the  blood  becomes  altered.  It  is  possible  that  the  encephaloid 
matter  developed  either  outside  or  within  the  walls  of  the  veins, 
might  penetrate  them,  and  produce  those  vegetations  which  have 
been  too  readily  attributed  to  a  transformation  of  the  blood. 

B.  The  modifications  to  which  lymph  is  subjected  in  the  course 

*  Revue  Medicale,  1825  and  1826. 


NECROSCOPY.  375 

of  disease  cannot  be  detected  during  life,  but  may  be  sometimes 
appreciated  after  death. 

In  women  who  die  of  puerperal  fever,  pus  is  frequently  found 
in  the  lymphatic  vessels  of  the  uterus.  We  have  seen,  in  a  case 
of  cancerous  affection  of  the  stomach  and  mesenteric  glands,  the 
lymphatic  vessels  of  the  mesentery  distended  with  pus  so  as  to 
make  them  much  more  distinct  than  could  have  been  done  by  the 
most  perfect  injection.  Since  Cruikshank,*  bile  has  frequently 
been  found  in  the  lymphatics  of  the  liver.  Sabatier,f  Soemmering  J 
and  many  others  have  seen  in  the  thoracic  duct,  a  liquid  resem- 
bling the  blood  in  color  and  consistence,  and  have  admitted  that  this 
fluid  can  pass  directly  into  the  lymphatic  vessels.  These  observa- 
tions, however,  are  far  from  conclusive,  and  it  is,  in  our  opinion, 
with  reason  that  of  late,  Miiller  and  Breschet$  have  raised  doubts 
as  to  the  nature  of  the  red  fluid  found  in  the  lymphatic  system. 

C.  The  mucous  membranes,  which  open  externally  by  one  or 
more  orifices,  sometimes  permit  a  portion  of  the  fluid  which  lubri- 
cates them,  to  escape  by  the  mouth,  anus,  urethra  or  vagina,  espe- 
cially when  the  secretion  is  increased  in  quantity.     But  even,  in 
these  cases,  it  is  not  uninteresting  to  examine,  after  death,  the  mu- 
cus contained  in  the  air  and  digestive  passages,  bladder  and  uterus. 
It  is  not  unusual,  also,  to  find,  in  some  of  the  organs,  collections 
of  mucus,   which  have  not  been  voided  during  life.     The  fluid 
should  be  examined  after  death,  as  during  life,  with  regard  to  the 
alterations  in  quantity,  consistence,  color,  and  admixture  with  other 
substances  caused  by  disease. 

D.  It  is  particularly  for  the  study  of  the  liquids  enclosed  in  the 
serous  membranes,  that  post-mortem  examinations  are  indispensa- 
ble, the  disposition  of  these  membranes  preventing,  during  life,  an 
examination  of  their  contents.     It  is,    in  fact,  only  by  the  aid  of 
rational  signs  that  we  can  ascertain  the  presence,   increase  or  di- 
minution of  fluid  within  their  cavities,  or  whether  they  are  lined 
with  false   membranes.     It   is  true    that  sometimes  by  a  special 
operation  we  can  see,  and  subject  to  close  examination,  the  fluids 
taken  from  the  serous  cavities.     But  such  operations  are  rarely 
practised,  and  the  whole  fluid  is  never  withdrawn  ;  the  denser  por- 
tions subside  to  the  dependent  part  of  the  cavity,  and  the  mem- 
braniform  concretions  are  generally  adherent  and  cannot  escape : 
an  examination  of  the  body  can  then  alone  give  a  correct  knowl- 
edge of  the  morbid  products  contained  in  serous  membranes.    The 
fluids  found  in  them  may  be  colorless  or  watery,  transparent, 
clouded  or  completely  opaque,  and  may  sometimes  consist  of  pus 
or  blood,  pure  or  mixed  with  serum.     With  these  liquids  we  often 

*  Anat.  des  Vaisseaux  Abs.  p.  8,  trad,  de  Petit  Radel. 
f  Hist,  de  VAcnd.  des  Sciences,  annee  1780. 
j  De  Mortis  vas  absorp.  p.  40. 
§  Systeme  Lymphat.  p.  288. 


376  NECROSCOPY. 

find  various  concretions  in  the  form  of  flakes,  bridles  or  false 
membranes  sometimes  intimately  blended  with  the  sac,  so  as  to 
give  the  appearance  of  an  increased  thickness  of  the  walls  ;  a  close 
examination,  however,  will  show,  as  Prof.  Fouqnier  has  demon- 
strated, that  these  may  be  detached,  and  that  the  thickness  of  the 
membranes  is  not  increased.  We  may  add  that,  in  almost  all  cases, 
they  preserve  their  natural  transparency,  and  that  the  red  or  black 
color  which  they  sometimes  exhibit,  belongs  to  the  cellular  tissue 
adherent  to  their  surface;  this  is  readily  shown  by  careful  dissec- 
tion. The  false  membranes  above  mentioned,  may  be  either  sim- 
ple or  multiplied,  soft  or  firm,  presenting  the  greatest  variety 
of  color,  from  black  to  a  grayish  white.  They  assume,  in  a  short 
time,  often  in  a  few  hours,  the  appearance  of  organization.  Andral* 
having  injected  some  acetic  acid  into  the  pleura  of  a  rabbit,  found, 
at  the  expiration  of  nineteen  hours,  soft  false  membranes  penetrated 
by  numerous  reddish  lines,  which  anastomozed  like  blood-vessels. 
Cloquet  even  remarked  the  same  thing  in  persons  who  had  died  of 
pleurisy,  after  a  few  days'  sickness.  Are  these  red  lines  vessels  ? 
This  does  not  appear  to  us  sufficiently  demonstrated,  and  when 
we  remember  the  red  lines  seen  in  other  secretions,  as  in  bronchial 
mucus  and  in  the  glairy  matter  thrown  off  by  vomiting  or  stools, 
doubts  may  be  entertained  respecting  the  existence  of  these  acciden- 
tal vessels,  which  should  become  more  apparent  in  old  false  mem- 
branes where  they  have  never  hitherto  been  clearly  distinguished. 
On  the  other  hand,  in  these  false  membranes  are  found  blood  and 
small  tubercles,  which  would  demonstrate  a  real  organization,  if  it 
could  be  proved  that  the  blood  or  the  tubercles  were  produced  by 
them,  and  not  by  the  inflammation  of  the  serous  membrane  ;  this, 
however,  it  is  impossible  to  do.  We  may  consider  it  as  almost 
certain,  that,  in  serous  membranes  entirely  lined  by  them,  morbid 
deposits,  exhalation  and  absorption  nevertheless  continue  ;  but  do 
these  deposits  contain  exhalents  and  absorbents,  or  do  they  merely 
constitute  a  permeable  layer  into  which  the  mouths  of  these  ves- 
sels open  ?  In  the  present  state  of  the  science,  these  questions  do 
not  appear  to  us  settled. 

E.  The  liquids  contained  in  the  synovial  membranes  present 
alterations  analogous  to  those  of  the  serous.     In  addition  to  these, 
we  sometimes  find  in  them  free  or  movable  concretions,  the  pres- 
ence of  which  during  life  has  caused  severe  pains,  these  being  more 
or  less  constant,  according  to  the  part  of  the  articulation  occupied 
by  these  foreign  bodies. 

F.  The  fluid  contained  in  the  cellular  tissue  is  colorless  or  yel- 
low, muddy  or  purulent,  and,  in  some  cases,   mixed  with  blood. 
Examination  after  death  reveals  the  presence  of  serum  in  the  sub- 
cutaneous cellular  tissue,  in  that  between  the  muscles,  in  that  in 
the  interior  of  the  body,  as  in  the  cellular  tissue  of  the  peritoneum, 

*  Clin.  Medical,  vol.  iv,  p.  538,  4th  ed.  Par.  1840. 


NECROSCOPY.  377 

and  in  the  cellular  appendages  of  the  large  intestines.  Infiltration 
sometimes  exists  in  the  cellular  tissue  of  the  pleura,  and  in 
that  which  unites  the  pericardium  to  the  exterior  of  the  heart. 
Serum  has  sometimes  been  detected  in  the  cellular  tissue  which 
unites  the  mucous  membranes  to  the  adjacent  parts,  both  where  it 
is  external,  accessible  to  view,  and  where  it  exists  in  deeper  seated 
parts,  as  in  the  epiglotto-arytenoid  folds,  the  glottis,  and  the  valves 
of  the  intestines. 

G.  The  fluids  secreted  by  the  glands  present  some  alterations, 
but  most  of  them  are  appreciable  during  life,  except  in  the  case  of 
retention  of  these  liquids,  of  the  bile  and  urine,  for  instance,  in  their 
ducts  and  reservoirs.  Post-mortem  examination  of  the  biliary  and 
urinary  passages  sometimes  reveals,  in  these  cases,  very  interesting 
phenomena. 

H.  There  is  scarcely  any  cavity  in  which  we  may  not  find 
after  death  some  effusion,  circumscribed  or  diffused,  of  liquid  or 
coagulated  blood,  of  serous  or  thickened  pus,  with  or  without  a 
membraniform  envelope. 

I.  Fluids  enclosed  in  accidental  sacs  or  cysts  are  also  found 
upon  examination  of  bodies  after  death.  These  are  sometimes 
aqueous;  at  others,  viscid,  resembling  honey,  gelatine,  pus,  lard;  or 
they  may  be  of  a  cretaceous  character.  In  the  first  case,  the  cyst  is 
thin  and  resembles  the  serous  membranes;  in  the  others,  it  generally 
has  some  thickness;  it  is  often  fibrous,  and  sometimes  is  even  cartila- 
ginous or  bony.  Some  cysts  present  a  different  texture  in  different 
parts.  In  such  cases,  their  cavity  is  generally  divided,  by  irregular 
septa,  into  several  sacs,  each  of  which  may  contain  a  liquid  of  dif- 
erent  color  and  consistence ;  these  are  termed  multilocular  cysts. 

§  II.  Alterations  of  the  elastic  Fluids  or  Gases.  —  The  gas 
naturally  exhaled  in  the  alimentary  canal,  may,  upon  examination 
of  the  body  after  death,  exhibit  important  modifications  as  to  its 
quantity,  distribution  and  chemical  qualities.  This  latter  point 
has  been  as  yet  but  little  studied,  and  we  cannot  tell  what  advan- 
tages may  not  be  derived  from  a  more  careful  investigation.  The 
diminution  or  increase  in  the  quantity  of  gas  in  the  intestines 
and  stomach  may  be  ascertained  as  well  during  life  as  after 
death.  The  most  important  fact  to  note,  in  reference  to  Pathologi- 
cal Anatomy,  is  the  accumulation  of  gas  in  one  portion  of  the  canal 
whilst  another  contains  none,  or  less  than  its  usual  quantity ;  this 
is  a  most  sure  sign  of  some  contraction  or  stoppage,  or  other  obsta- 
cle to  the  passage  of  the  gas.  It  often  enlightens  the  physician 
upon  the  subject  of  his  investigations,  pointing  out  to  him,  in  some 
cases,  lesions  which  he  did  not  suspect  during  life,  and  which  even 
after  death,  surrounded  by  others  of  more  apparent  importance, 
such  as  peritonitis,  might  still  elude  his  search,  if  he  were  not  im- 
pressed with  the  value  of  this  phenomenon. 
32* 


378  NECROSCOPY. 

We  sometimes  meet  with  gas  in  parts  which  naturally  do  not 
contain  it,  as  in  the  pleura,  peritoneum  and  subcutaneous  cel- 
lular tissue,  very  rarely  in  a  cyst,  of  which  we  have  above  given 
an  example  (p.  283).  Some  physicians  suppose  that  these  gases 
may  result  from  a  simple  morbid  exhalation,  but  the  more  extended 
our  observations,  the  more  convinced  we  become  that  the  presence 
of  gas  in  the  pleura,  peritoneum  and  cellular  tissue,  is  almost 
always  the  result  of  a  perforation  of  the  intestines,  lungs,  or  some 
other  portions  of  the  air  passages,  as  the  trachea  or  nasal  fossre. 
We  should  therefore  examine  carefully  for  such  lesions.  The 
presence  of  gas  in  a  part  that  ought  not  to  contain  it,  is  sometimes 
a  phenomenon  of  putrefaction  after  death  *  and,  possibly,  in  some 
cases,  arises  from  the  decomposition  of  pus  confined  in  a  cyst, 
particularly  if  it  have  been  punctured. 

3d.  Series.  —  The  foreign  bodies  discovered  in  post-mortem  ex- 
aminations are  of  different  kinds ;  some  inanimate,  others  pos- 
sessed of  life,  or  previously  deprived  of  it.  Among  those  which 
are  inanimate,  some  are  found  in  the  body,  as  biliary  and  urinary 
calculi,  intestinal  concretions,  and  those  which  are  found  in  the 
articulations,  salivary  ducts,  lungs,  uterus,  etc.  Of  those  which 
come  from  without,  some  are  introduced  by  wounds,  particularly 
by  gunshot  wounds;  others  by  the  natural  passages,  as  the  mouth, 
anus,  urethra  in  both  sexes,  or  the  vagina  in  women. 

The  living  foreign  bodies  which  are  found  in  man  are  the  oxyu- 
res  or  ascarides  vermiculares,  which  are  found  particularly  in  the 
rectum,  the  ascarides  lumbricoides  in  the  small  intestines,  the  tri- 
cocephales  or  trichurides  in  the  ccecurn  of  those  who  die  of  typhoid 
fever,  and  many  varieties  of  taenise ;  the  tsenia  lata  is  the  most 
frequent  in  France,  and  is  generally  met  with  in  the  small  intes- 
tine. Hydatids  of  various  kinds  are  found  in  the  interior  of  the 
viscera,  or  in  the  splanchnic  cavities.  Those  called  by  Laennec 
acephalocysts  are  the  most  common,  and  are  generally  developed 
in  the  liver.  This  viscus  is  moreover  the  exclusive  seat  of  a  spe- 
cies of  entozoa  called  thefasciola  humana  by  Breza,  being  rarely 
found  in  man.  The  kidney  is  also  the  exclusive  seat  of  a  species 
of  entozoa  not  less  rare,  to  which  the  term  strongylus  has  been  ap- 
plied. In  Guinea,  a  long  white  slender  worm  called  the  Guinea 
worm,  or  dracunculus,  forms  in  the  flesh,  principally  affecting  the 
negro  race. 

Such  are  the  principal  phenomena  revealed  by  necroscopy. 

The  various  disorders    thus  disclosed  are  not  of  equal  impor- 

*  We  assisted  at  the  opening  of  a  stout  man  who  had  died  suddenly  thirty-two 
hours  before.  The  emphysema  which  had  come  on  since  death  was  already  so 
considerable  as  that  the  volume  of  the  trunk  and  limbs  was  nearly  double  their 
natural  size.  The  moment  the  scalpel  penetrated  the  abdomen,  which  was  as  hard 
as  a  board,  the  air  escaped,  producing  an  explosion  as  violent  as  that  of  a  well 
charged  air  gun.  The  alimentary  canal  had  not  been  wounded,  and  remained 
distended.  The  gas  which  produced  the  explosion  was  therefore  collected  in  the 
peritoneum  itself.  The  emphysema  was  so  general,  that  it  escaped  with  the  blood 
in  the  form  of  a  reddish  froth  upon  incising  the  vessels. 


NECROSCOPY.  379 

tance.  1.  Some  precede  the  symptoms  of  the  disease,  and  appear 
to  have  produced  them,  such  as  crude  tubercles,  which  are  often  met 
with  in  the  lungs  of  persons  whose  respiration  has  not  seemed  af- 
fected. 2.  There  are  other  alterations  which  only  supervene  in 
the  course  of  a  disease,  sometimes  at  a  very  advanced  stage,  and 
which  seem  rather  the  effect  than  the  cause ;  such  as  the  tume- 
faction of  the  liver,  and  the  anasarca  in  persons  affected  with 
aneurism  of  the  heart.  3.  Other  phenomena  of  pathological  anat- 
omy only  occur  in  the  last  moments  of  life,  as  the  engorgement  of  the 
lungs  above  mentioned  (p.  367),  and  also,  doubtless,  the  gelatin- 
ous and  albuminous  clots  found  in  the  heart  and  large  vessels. 
4.  Many  lesions  only  take  place  after  death,  and  are  called  ca- 
daveric phenomena,  as  the  purple  spots  formed  in  the  subcutaneous 
cellular  tissue,  the  transudation  of  bile  which  colors  the  neighbor- 
ing parts  of  the  intestines,  the  stomach  and  the  inferior  surface  of 
the  liver ;  the  disengagement  of  air  which  may  take  place  in  a 
very  short  time,  less  than  twenty-four  hours,  for  example ;  the  in- 
filtration, which  supervenes  after  death,  and  which  is  more  fre- 
quent under  some  atmospheric  conditions,  and  possibly  after  par- 
ticular diseases ;  the  slight  effusion  of  serum  found  in  the  serous 
membranes ;  the  putrefaction  which  is  generally  much  more  rapid 
in  some  parts  than  in  others,  and  which  on  this  very  account  will 
be  liable  to  lead  to  error ;  to  these  may  be  added  certain  changes 
in  the  gastric  mucous  membrane,  which,  as  Dr.  CarswelPs  experi- 
ments have  proved,  may  supervene  after  death  by  the  corrosive 
action  of  the  gastric  juice  upon  the  walls  of  the  stomach,  and  may 
lead  us  to  suspect  the  action  of  some  caustic  poison.  Lastly, 
there  are  lesions  which  are  met  with  after  death,  but  which 
during  life  produced  no  apparent  trouble  in  the  functions,  such  as 
adhesions  of  the  lungs  to  the  walls  of  the  thorax,  the  white  and 
opaque  spots  that  often  exist  upon  the  heart,  certain  encysted  tu- 
mors, various  foreign  bodies,  and  some  incipient  organic  lesions. 

It  is  of  the  highest  importance  to  the  physician  nicely  to  appre- 
ciate these  different  phenomena.  It  is  with  reason  that  Double  in 
his  "  Traite  de  Semeiotique,"*  pointed  out  the  errors  to  which  post- 
mortem examinations  may  give  rise,  especially  at  a  time  when  we 
are  possibly  disposed  to  give  an  undue  importance  to  anatomical 
lesions ;  but  we  do  not  consider  these  errors  as  unavoidable,  and 
think  that  it  is  often  possible,  by  carefully  comparing  and  collat- 
ing the  phenomena  observed  during  life,  and  the  lesions  found 
after  death,  to  distinguish,  among  these  lesions,  those  which  have 
preceded,  and  those  which  have  followed  the  development  of  the 
symptoms  and  the  death  of  the  individual.  —  O. 

*  S&m&iotique  Ginirale,  vol.  i.  p.  56,  et  seq. 


380  THERAPEUTICS. 


CHAPTER  XIX. 


THERAPEUTICS. 

IN  man,  as  in  other  organized  beings,  there  exists  an  internal 
force,  which  presides  over  all  the  phenomena  of  life,  in  each  of  its 
successive  periods,  contends  unremittingly  with  physical  and 
chemical  laws,  receives  the  impression  of  deleterious  agents,  reacts 
against  them,  and  consequently  developes  the  symptoms,  deter- 
mines the  course  and  eifects  the  resolution  of  diseases,  by  an  action 
equally  impenetrable  in  all.  This  force,  which  constitutes  life, 
commencing  and  ceasing  with  it,  inherent  in  the  organs,  arid, 
(were  it  not  for  its  abandonment  of  them  after  a  certain  time,)  in- 
separable from  them,  wholly  unknown  as  to  its  essential  nature, 
and  manifested  by  its  effects  alone,  while  it  has  been  termed  by 
certain  authors  vital  force  and  internal  power,  has  been  more 
generally  known  by  the  name  nature,*  from  the  times  of  Hippo- 
crates downward.  While  physicians  admit  the  existence  of  this 
force,  they  are  not  agreed  in  regard  to  its  attributes :  some  have 
considered  it  an  intelligent  principle!  all  of  whose  acts  are  the 
result  of  reasoning,  and,  as  it  were,  voluntary ;  others,  going  to 
the  opposite  extreme,  make  nature  to  consist  in  the  elasticity  and 
oscillation  of  the  fibres,  and  in  the  progressive  and  circulatory 
motion  of  the  fluids  ;J  others,  as  Sydenham,^  have  used  the  term 
in  the  same  sense  which  we  attach  to  it  at  the  present  day. 

Cure,  or  the  transition  from  disease  to  health,  is  the  result  of  a 
profound  change  effected  in  our  organs,  itself  necessarily  subordi- 
nate to  the  power  presiding  over  all  the  vital  phenomena :  upon 
this  power,  therefore,  the  cure  depends.  From  the  fact,  however, 
that  many  circumstances  may  embarrass  or  assist  its  action,  art 
concurs,  more  or  less  efficiently,  in  the  cure  of  diseases,  by  prop- 
erly directing  and  proportioning  the  efforts  of  nature,  and  removing 
the  obstacles  likely  to  oppose  them.  Such  is  the  office  of  thera- 
peutics^ (therapeutice),  the  branch  of  pathology  devoted  to  the 
treatment  of  diseases.  To  treat  a  disease,  is  to  remove  everything 
likely  to  exert  upon  it  an  untoward  influence,  and  to  combine  all 
those  means  suitable  for  the  diminution  of  its  duration  and  inten- 
sity. 

The  majority  of  diseases  are  susceptible  of  cure  without  active 
treatment,  by  the  powers  of  nature  alone;  from  this  arises  the 
usurped  reputation  of  an  infinite  number  of  inefficacious  remedies 
and  of  a  crowd  of  ignorant  charlatans.  No  disease  can  be  cured 
by  art  alone ;  hence  the  impotency  of  medicine  in  a  great  num- 

*  tjF>?'(T(?,  nature. 

t  VAN-HELMONT. 

t  RAYMOND,  Maladie  qu'il  est  dangereux  de  Guerir.  p.  20. 

\  Opera  Omnia,  t.  i.  p.  77,  78. 

II  OtQanivw,  I  take  care  of. 


THERAPEUTICS.  381 

her  of  the  diseases  which  afflict  mankind.  Cinchona  and  the 
mercurial  preparations,  justly  considered  the  most  heroic  remedies 
we  possess,  are  powerless  when  nature  does  not  respond  to  their 
action.  Biood-letting  alone  will  not  dissipate  inflammation,  and 
the  adaptation  of  the  edges  of  a  wound  is  not  sufficient  to  effect 
reunion.  In  surgery,  as  in  medicine,  therapeutics,  (in  the  great 
majority  of  cases)  merely  favor  the  action  of  nature,  which,  unas- 
sisted, would  be  able  to  restore  an  inflamed  organ  to  the  healthy 
state,  cicatrize  a  wound  and  unite  the  fragments  of  a  broken  bone. 

Therapeutics,  properly  denned,  is  but  the  art  of  modifying  the 
secret  action  of  our  organs,  for  the  purpose  of  curing  or  alleviating 
disease.  This  assertion  seems  to  us  incontestable,  even  by  the 
most  strenuous  advocates  of  the  power  of  artificial  means.  No 
one  will  imagine  that  we  intend  to  diminish  the  claims  of  remedial 
measures  in  the  cure  of  disease :  on  the  contrary,  we  are  con- 
vinced, that  by  the  omission  of  suitable  treatment,  and  especially 
by  the  influence  of  improper  medication,  very  slight  affections 
even,  may  become  incurable  or  fatal ;  that  the  greater  part  of 
severe  diseases  would  terminate  in  death ;  that  many  others,  among 
which  should  be  classed  certain  forms  of  syphilis,  would  not  admit 
of  cure,  at  any  rate,  in  our  climate  :  we  only  intend  to  say  that 
our  therapeutical  means  have  no  direct  action  upon  disease,  that 
they  act  only  by  determining  modifications  in  the  economy,  by 
means  of  which  that  favorable  change  which  prepares  and  com- 
pletes the  cure,  is  effected :  the  extraction  of  foreign  bodies  and 
the  reduction  of  displaced  parts  are  almost  the  only  exceptions. 
This  doctrine,  generally  admitted  at  the  present  day,  detracts 
nothing  from  the  importance  of  therapeutics,  and  gives  to  nature 
the  influence  belonging  to  it:  equally  removed  from  the  opinions 
of  those  who  ascribe  the  exclusive  merit  of  a  cure  to  art  or  to  na- 
ture, we  believe  that  the  concurrence  of  both  is  always  useful  and 
often  indispensable. 

This  mode  of  considering  therapeutics  exhibits  also,  its  bases : 
these  are,  first,  the  thorough  knowledge  of  the  course  and  tendency 
of  diseases  towards  various  terminations,  and,  secondly,  a  like 
knowledge  of  the  proper  means  for  opposing  or  assisting  these 
tendencies :  observation  and  experience  alone  can  direct  us  in  this 
difficult  study. 

Observation,  in  medicine  as  well  as  in  all  the  other  sciences,  re- 
quires, in  those  about  to  devote  themselves  to  it,  the  perfection 
of  the  senses,  and  a  mind  at  once  attentive,  calm  and  unprejudiced. 
Perfect  senses  are  necessary,  because  by  them  are  established  those 
relations  between  physician  and  patient  which  lead  to  the  knowl- 
edge of  the  disease.  The  entire  attention  is  indispensable;  he 
who  cannot  command  this,  is  incapable  of  proper  observation,  and 
whatever  tends  to  divert  or  enfeeble  it,  as  fatigue  of  mind  or  preju- 
dice, will  disqualify  even  an  individual  who  would  otherwise  be 
an  excellent  observer.  For  this  reason,  meditation,  previous  to 
visiting  patients,  is  injurious  to  the  physician,  and  it  was  not  with- 
out a  sufficient  motive  that  Hippocrates  recommended  them  to  be 


382  THERAPEUTICS. 

seen  in  the  morning  rather  than  at  evening,  asserting  that  the 
physician  is  more  likely  to  observe  well  at  that  hour,  as  is  the 
patient  to  reply  more  distinctly  to  questions.  The  most  complete 
composure  is  equally  necessary  to  the  observer;  any  strong  passion 
absorbs,  as  it  were,  all  the  moral  faculties  and  prevents  the  con- 
centration of  the  mind  upon  other  objects.  A  tender  attachment 
or  too  lively  anxiety  incapacitate  one  for  thorough  observation  and 
accurate  appreciation  of  existing  phenomena.  It  is  a  common 
remark,  that  a  physician  nearly  always  errs  in  his  opinions  in  re- 
gard to  the  diseases  by  which  his  intimate  friends  are  affected  ; 
still  more  decidedly  is  this  the  case  in  respect  to  affections  of  which 
he  himself  is  the  subject :  on  this  account  it  has  become  an  estab- 
lished principle  that,  in  all  such  cases,  no  wise  man  should  rely 
upon  himself.  In  order  to  correct  observation,  the  mind  should  be 
free  from  prejudice,  which,  as  has  been  remarked,  is  a  kind  of 
prism,  concealing  from  our  view  one  portion  of  objects  and  mag- 
nifying arid  distorting  the  other,  thus  presenting  an  image  more 
or  less  incorrect  and  always  very  imperfect.  Systematic  physi- 
cians have  ever  been,  and  always  will  be,  unskilful  observers.  He 
who,  in  accosting  patients,  is  not  satisfied  with  the  application  of 
his  senses  to  the  examination  of  phenomena,  and  with  the  recep- 
tion of  impressions  transmitted  by  them,  but  searches  for,  and 
wishes  to  find,  in  what  he  observes,  the  confirmation  of  previous 
imaginations,  is  wholly  unfit  for  an  observer,  and  the  results  of 
his  observation  are  generally  nothing  more  than  the  vagaries  of  a 
deranged  mind. 

A  quality  more  important  than  any  previously  enumerated, 
should  be  added  to  the  above  requisites  :  viz.  the  spirit  of  observa- 
tion. This  quality,  which  implies  the  union  of  all  the  others,  but 
does  not  always  accompany  them,  consists  simultaneously  in  a  sort 
of  natural  inclination  to  examine  objects  attentively,  and  in  the 
faculty  of  promptly  detecting  and  appreciating  their  relations  and 
discrepancies.  It  is  an  innate  disposition,  capable  of  development 
by  cultivation,  but  not  of  acquisition  by  those  who  do  not  natu- 
rally possess  it.  Sound  judgment  is  also  indispensable  to  the  phy- 
sician, to  enable  him  to  rise  gradually,  and  in  the  proper  order,  from 
the  isolated  observation  of  particular  facts  to  those  general  con- 
clusions whose  assemblage  constitutes  pathological  physiology. 

A  physician  long  accustomed  to  accurate  observation,  can,  from 
the  nature  and  form  of  diseases,  their  intensity,  course,  period, 
etc.,  without  other  aid,  accurately  appreciate  their  tendencies  to 
various  terminations,  and,  consequently,  can  decide  upon  the  fit- 
ting opportunity  for  active  treatment,  or  prudent  expectation,  which 
is  never,  properly  speaking,  a  state  of  inaction,  for  it  supposes,  on 
the  part  of  the  physician,  a  vigilant  attention,  necessary,  not  only 
in  opposing  the  accidents  which  may  supervene,  and  in  removing 
everything  likely  to  disturb  the  progress  of  a  disease  approaching 
a  favorable  termination,  but,  moreover,  in  uniting  all  the  hygienic 
conditions  most  favorable  to  a  prompt  and  complete  cure.  We 
can  understand  how  dangerous  is  that  ignorant  treatment  that 


THERAPEUTICS.  383 

torments  with  powerful  remedies  a  disease,  over  which  the  natural 
powers  alone  would  prevail,  or  that  unseasonable  expectation 
which  delays  action  in  presence  of  a  disease  sufficiently  severe  to 
compromise  life,  and  whose  fatal  termination  might  have  been  pre- 
vented by  active  medication.  Observation  alone  can  preserve  the 
physician  from  these  fatal  errors,  because  it  alone  furnishes  that 
thorough  knowledge  of  the  course  and  connection  of  pathological 
phenomena,  constituting  an  unfailing  rule  in  the  treatment  of  dis- 
ease. 

If  the  study  of  the  various  tendencies  of  diseases  be  difficult, 
the  appreciation  of  the  suitable  means  for  favorably  modifying 
organic  action  is  no  less  so ;  it  is  based  upon  experience,  whose 
foundation  is  a  combination  of  observation  and  experiment.  "  Ex- 
periment (exp&rimentum)  differs  from  simple  observation  in  this, 
that  the  knowledge  we  acquire  from  mere  observation  seems  to  be 
freely  presented,  while  that  furnished  by  experiment  is  the  result 
of  some  trial,  made  with  the  intention  of  ascertaining  the  exist- 
ence or  non-existence  of  a  thing.  A  physician  who  atten- 
tively considers  everything  in  the  course  of  a  disease,  observes ; 
and  he  who,  in  similar  circumstances,  administers  a  remedy  and 
endeavors  to  appreciate  its  effects,  experiments.  Thus  the  ob- 
serving physician  listens  to  nature,  the  experimentalist  questions 
her."* 

Observation  occupies  the  first  rank  in  the  delicate  study  of  the- 
rapeutical means.  It  necessarily  preceded  experiment  in  the  natural 
concatenation  of  human  ideas  and  acquirements.  Those  who 
were  first  led  to  attempt  the  relief  of  their  species  probably  de- 
rived their  original  notions  from  chance,  and  occasionally  from  the 
instinct  of  the  patients,  and  doubtless  tried  no  experiment  until  a 
subsequent  period.  We  have  previously  enumerated  the  condi- 
tions requisite  for  observation  and  will  now  attempt  to  sketch  the 
rules  which  should  regulate  experimentation. 

Therapeutical  experimentation  seems  the  most  simple  and  easy 
thing  possible,  not  only  to  persons  unacquainted  with  medicine, 
but  also  to  the  majority  of  practitioners.  There  is  no  physician 
but  has  experimented  more  or  less  with  remedies,  and  drawn  more 
or  less  positive  conclusions  from  his  experiments  ;  yet  we  all  know 
how  few  of  such  conclusions  have  received  the  sanction  of  time, 
and,  consequently,  how  few  there  are  who  appreciate  the  difficul- 
ties of  experimentation  and  the  great  circumspection  and  persever- 
ance it  demands  in  order  to  obtain  accurate  results.  The  number 
of  medicines  declared  by  various  experimentalists  to  be  capable  of 
arresting  the  course  of  intermittent  fever  may  be  estimated  at 
several  hundred,  and  yet,  among  them  all,  there  is  but  one  whose 
action  as  a  febrifuge  is  fully  proved  and  universally  admitted,  f 

*  ZIMMERMAN,  de  V Experience,  t.  i.  p.  22. 

f  Although  the  unfailing  specific  action  of  the  sulphate  of  quinine  has  so  firmly 
and  justly  established  it  as  the  remedy  par  excellence  in  intermittent  fevers,  we  are 
inclined  to  consider  the  assertion  that  it  is  "  the  only  one  whose  action  as  a  febri- 
fuge is  fully  proved  and  universally  admitted"  as  somewhat  too  positive.  We 


384  THERAPEUTICS. 

The  number  of  remedies  vaunted  as  specifics  in  certain  other  dis- 
eases, as  epilepsy  or  gout,  is  hardly  less  considerable,  and  none  of 
them  have  stood  the  test  of  time  and  justified  the  confidence  too  has- 
tily accorded  to  them  by  some  experimentalists.  The  immediate 
consequences  of  these  facts  are,  that  experimentation  in  medicine  is 
extremely  difficult,  and  exact  experimenters,  unfortunately,  very 
rare. 

Some  experiments  are  undertaken  with  a  view  to  determine 
the  action  of  certain  therapeutical  agents  in  a  given  disease ; 
others,  to  ascertain  the  primitive  effect  of  a  medicine  upon 
the  economy,  as  its  purgative,  diuretic  or  sudorific  action. 
The  latter  by  no  means  present  equal  difficulties  with  the  former, 


have  the  best  authority  for  the  use  of  arsenical  preparations  in  intermittents. 
Among  many  writers  who  recommend  them,  may  be  mentioned  Pereira,  Copland, 
Marshall  Hall,  and  Watson  ;  every  one  is  familiar  with  the  extraordinary  success 
which  attended  the  use  of  the  arsenical  solution  in  the  hands  of  its  originator. 
(Med.  Reports  on  the  effects  of  arsenic  in  the  cure  of  agues,  remittent  fevers  and 
periodic  headache. — T.  Fowler,  1786.)  This  is  mentioned  by  MM.  Trousseau 
and  Pidoux  ;  (Traite  de  Thtrapeutique  et  de  Mali  ere  Mfdtcale,  %me  edition,  torn. 
i.  p.  302  ;)  they  also  cite  the  strong  testimony  of  Willan  in  its  favor,  who  declared 
"  that  he  knew  no  remedy  more  sure,  efficacious  or  convenient  to  take,  than  this 
arsenical  solution  in  the  treatment  of  intermittents  ."  MM.  Trousseau  and  Pi- 
doux remark,  that  "  no  one  can  hesitate,  at  the  present  day,  to  consider  arsenic  as 
nearly  upon  the  same  footing  with  quinine,  as  a  febrifuge."  —  (Op.  cit.  p.  303.) 
A  very  elaborate  and  highly  interesting  paper  upon  the  use  and  efficiency  of  ar- 
senic in  intermittent  fevers,  by  M.  F.  Masselot,  is  published  in  the  Archives  Gen- 
erales  de  Medecine  ;  (4me  Serie,  torn.  x.  et  xt.)  several  cases  are  given  where  the 
sulphate  of  quinine  had  arrested  the  paroxysms  of  the  disease,  but  recurrence 
occurring,  definitive  cure  was  obtained  by  the  employment  of  arsenious  acid  in 
conjunction  with  emetics.  Many  important  and  positive  inferences  are  deduced 
by  the  author  from  his  researches,  apparently  with  the  greatest  reason.  The  ex- 
perience of  M.  Boudin  in  the  Military  Hospital  at  Versailles,  is  conclusive  in  favor 
of  this  remedy.  From  a  table  given  by  M.  Masselot,  (loc.  supra  cit.)  we  extract 
the  following  :  "  Patients  treated  by  sulphate  of  quinine,  111;  return  of  the  parox- 
ysms in  14  cases,  12.5  in  100 :  —  Patients  treated  by  arsenious  acid,  311  ;  return 
of  the  paroxysms  in  10  cases,  3.2  in  100."  Most  authors,  also,  testify  to  the  effi- 
cacy of  the  alkaloid  salicin  in  intermittents  ;  it  possesses  very  analogous  properties 
with  the  sulphate  of  quinine,  being,  like  that  salt,  an  astringent  tonic  :  some  have 
erroneously  ascribed  to  it  an  equal  and  even  a  superior  efficacy  to  quinine  ;  this 
position  it  certainly  does  not  hold,  and  probably  never  will,  but  in  cases  where  the 
latter  medicine  could  not  be  obtained,  salicin  would  be  an  invaluable  substitute. — 
(Dr.  Shapter,  Intermittent  Fever,  Lib.  Pract.Med.  —  Tweedie.  Am.  ed.  vol.  i.  p. 
254.  —  Pereira,  Mat.  Med.  and  Therap.)  Although  it  requires  to  be  exhibited  in 
larger  doses  than  the  sulphate  of  quinine,  it  is  less  likely  to  irritate  the  stomach, 
(Pereira,  Op.  cit.  vol.  ii.  p.  187,  Amer.  edit.)  which  is  a  decided  advantage. 
Miquel  accords  to  it  a  distinguished  place  among  febrifuge  agents. —  (Gazette  M&di- 
cale  de  Paris,  Janvier,  1830.)  Magendie  has  seen  intermittents  cut  short  in  one 
day  by  three  doses  of  six  grains  each.  —  (Wood.)  Trousseau  and  Pidoux, 
as  also  Grisolle  (Path.  Int.)  wholly  deny  its  febrifuge  action,  but  the  weight  of 
evidence  is  certainly  very  decidedly  in  favor  of  it.  While,  therefore,  the  suprem- 
acy of  quinine  as  a  febrifuge  should  be  acknowledged,  can  it  be  said  that  no  other 
medicine  possssses  a  c'early  demonstrated  and  universally  admitted  febrifugal 
action?  Arsenic  certainly  fulfils  both  conditions,  and  the  febrifuge  qualities  of 
salicin  are,  as  it  seems  to  us,  "  fully  proved,"  if  not  "universally  admitted." 
—  TRANS. 


THERAPEUTICS.  385 

and  yet,  how  many  medicines  have  been  entitled  diuretics,  dia- 
phoretics and  even  purgatives,  whose  action  does  not  at  all  justify 
the  appellations  !  What  physician  has  not  experienced,  in  many 
diseases,  the  impossibility  of  augmenting  the  urinary  secretion  or 
of  exciting  abundant  perspiration  when  the  system  refuses  its  con- 
currence ?  This  kind  of  experimentation  is  not,  then,  free  from 
difficulties,  but  as  these  are  far  more  numerous  when  the  object  of 
experiment  is  the  observation  of  remedial  action  upon  the  progress 
of  a  disease,  the  rules  we  are  about  to  propose  for  the  latter,  will 
be  applicable,  a  fortiori,  to  the  former. 

A  physician  who  experiments,  should,  in  the  first  place,  know 
thoroughly  the  nature  of  the  medicine  whose  effects  he  would  ap- 
preciate, the  individual  upon  whom  it  is  to  be  tried,  and  the  dis- 
ease for  which  the  remedy  is  employed. 

The  first  duty  of  the  physician,  then,  is  to  know  thoroughly  the 
nature  of  the  remedy  about  to  be  tried ;  that  is  to  say,  no  trials 
should  be  made  with  medicines  of  whose  composition  he  is  igno- 
rant. The  Royal  Academy  of  Medicine,  authorized  by  govern- 
ment to  estimate  the  value  of  secret  remedies,  has  adopted  two 
rules,  first,  to  demand  from  the  holders  of  such  secrets,  the  exact 
composition  of  thfc  medicines,  and  secondly,  to  have  them  prepared 
by  an  apothecary  of  their  own  selection.  These  wise  precautions 
should  influence  those  physicians  who  are  requested  to  experiment 
with  any  therapeutical  preparation.  We  once  departed  from  this 
rule,  in  favor  of  a  respectable  physician,  who,  without  disclosing  its 
composition,  requested  us  to  make  trial  of  a  remedy  in  his  posses- 
sion, upon  the  success  of  which  his  future  expectations  and  the  sup- 
port of  a  numerous  family  depended.  Although  the  experiments 
were  favorable,  and  the  remedy  appeared  more  efficacious  than  any 
that  have  been  extolled  in  the  same  disease  (tcenia),  we  have  since 
regretted  having  consented  to  its  trial  without  knowing  its  com- 
position, and  from  that  time  have  uniformly  refused  all  similar 
requests. 

A  knowledge  of  the  composition  of  the  simple  or  compound 
remedy  submitted  to  him,  should  always  be  the  first  condition 
upon  which  the  physician  should  insist;  he  should  know  whether 
it  has  been  previously  employed,  and  by  whom,  whether  by  one 
physician  only,  or  by  several ;  and  if  in  a  few  cases,  or  very  fre- 
quently. If  it  have  been  often  employed,  and  no  accidents  what- 
ever have  occurred,  the  only  doubt  being  in  regard  to  its  remedial 
efficacy,  we  may  proceed  with  security,  restricting  ourselves  to  the 
customary  doses.  But  if  no  previous  trials  have  been  made,  and 
particularly,  if  the  article  be  an  extract  from  a  vegetable  substance, 
in  itself  active,  or  belonging  to  a  genus  of  plants  containing  poison- 
ous varieties ;  or  if  it  be  a  mineral,  some  of  whose  preparations  are 
energetic  in  their  action ;  if  experiments  upon  animals  have  re- 
vealed in  the  remedy,  or  in  combinations  containing  it,  an  action 
sufficiently  powerful  to  compromise  life  ;  if  it  have  a  strong  taste, 
or  if,  when  applied  to  the  skin,  it  cause  redness,  vesication  or  gan- 
grene, too  much  circumspection  cannot  be  exercised  in  the  first 
33 


3S6  THERAPEUTICS. 

trials  to  which  it  is  subjected.  The  formidable  accidents,  whose 
sudden  manifestation  we  witnessed  in  a  patient  at  the  Hospital  La 
Charite,  will  always  be  vividly  remembered.  We  were  adminis- 
tering a  substance  at  that  time  lately  extracted  by  MM.  Pelletier 
and  Caventou  from  nux  vornica,  and  called  by  them  vauqueline,  a 
name  since  exchanged  for  strychnine,  at  the  particular  request  of 
the  excellent  Vauquelin.  M.  Pelletier  having  requested  us  to  exper- 
iment with  this  extract,  which,  in  his  opinion,  acted  more  ener- 
getically and  equably  than  the  other  preparations  of  nux  vomica, 
a  young  man  affected  with  paraplegia  was  selected  for  the  experi- 
ment, to  whom  the  alcoholic  extract  of  nux  vomica  had  been  ad- 
ministered for  many  weeks,  a  dose  of  thirty-two  grains,  daily, 
having  been  attained  [26. 1-4  grs.  Troy]  without  the  slightest  in- 
fluence upon  the  muscles.  We  received,  from  M.  Pelletier,  six 
pills,  each  containing  one  quarter  of  a  grain  of  strychnine  [.2058 
gr.  Troy] ;  one  was  given  to  the  patient  the  first  day,  two,  at  one 
dose,  the  second,  three,  in  one  dose,  the  third  day,  without  the 
least  effect;  (1.1-2  Fr.  grains  =  1.23.  grs.  Troy.]  A  new  supply 
of  the  remedy  was  sent  for,  in  half  grain  doses ;  M.  Pelletier  fur- 
nished us  with  two  pills  only,  each  containing  one  grain,  being  all 
that  he  had  prepared.  Supposing  that  a  dose  off>ne  grain,  exhib- 
ited to  a  patient  who  had  taken  three  quarters  of  a  grain  on  the 
previous  evening,  without  effect,  and,  some  days  before,  thirty-two 
grains  of  another  preparation  of  the  same  remedy,  would  probably 
obtain  no  result,  and  that,  having  afterwards  but  one  similar  dose 
to  administer,  it  would  be  impossible  to  give  M.  Pelletier  the  in- 
formation he  desired,  we  committed  the  error  of  passing  at  once 
from  three  quarters  of  a  grain  to  two  grains  of  a  substance  whose 
degree  of  energy  was  unknown.  About  a  quarter  of  an  hour  after 
the  administration  of  the  remedy,  and  even  before  the  visit  in  the 
ward  St.  Louis,  in  which  the  patient  was,  was  completed,  he  was 
seized  with  convulsive  movements,  confined,  at  first,  to  the  limbs, 
afterwards  extending  to  the  respiratory  muscles,  and  fully  as  in- 
tense as  in  the  most  severe  cases  of  tetanus,  causing,  at  very  short 
intervals,  suffocation  so  imminent,  that,  for  more  than  half  an  hour, 
we  momentarily  feared  the  death  of  the  patient  from  the  violence 
and  duration  of  the  convulsive  action  of  the  diaphragm.  Our  anx- 
iety at  this  time,  it  would  be  impossible  to  express ;  the  necessity 
of  concealing  it  from  the  patient  rendered  it  still  more  distressing. 
We  remained  constantly  at  his  bed-side,  deeming  it  an  imperative 
duty  to  entrust  to  no  one  the  care  and  responsibility  of  so  fearful  a 
position.  Judging,  from  its  effects,  that  the  medicine  would  be  ab- 
sorbed by  the  stomach,  we  refrained  from  exciting  emesis,  for 
which  (the  above  opinion  being  correct)  there  was  no  occasion, 
and  which,  also,  by  the  muscular  contraction  it  causes,  might  have 
increased  the  violence  of  the  convulsions,  thus  adding  considerably 
to  the  threatened  danger.  A  dose  of  wine  of  opium,  equivalent  to 
about  ten  centigrammes  (two  grains)  [1.64  grs.  Troy]  of  solid 
opium,  was  given  immediately;  the  convulsions  and  suffocative 
symptoms  persisting  and  even  increasing,  the  dose  was  repeated 


THERAPEUTICS.  387 

five  minutes  after  the  first,  and  afterwards,  every  five  minutes,  and 
even  at  shorter  intervals,  double  the  above  quantity  was  adminis- 
tered ;  the  narcotism  that  might  be  expected  to  supervene  from  so 
large  doses  of  opium,  not  being  so  dangerous,  nor  the  peril  so  imme- 
diate, as  that  resulting  from  the  action  of  the  strychnine.  Finally, 
after  a  half  or  three  quarters  of  an  hour's  effort  and  anxiety,  the 
spasms  were  separated  by  longer  intervals,  and  the  suffocation  was 
less  threatening;  gradually,  and  in  the  space  of  a  quarter  of  an 
hour,  all  the  symptoms  produced  by  the  strychnine  had  disappeared, 
and  no  effect  was  observed  from  the  enormous  quantity  of  laudanum 
taken  by  the  patient,  (about  half  an  ounce)  except  slight  somno- 
lency, of  a  few  hours  duration,  from  which  he  was  easily  aroused. 
We  have  often  related  the  above  case  in  our  clinical  lectures  at  La 
Charite  and  the  Hotel  Dieu,  for  the  same  reason  that  induces  us  to 
give  it  a  place  in  the  present  work,  viz.  to  show,  by  this  example, 
to  those  who  listened  to  the  lectures  above  mentioned,  as  well  as 
to  those  who  may  peruse  this  volume,  with  what  circumspection 
experimentation  with  a  remedy  of  undetermined  power  should  be 
conducted.  We  would  even  add,  that  when  such  active  remedies 
have  been  prescribed  for  a  long  time  to  the  same  patient,  it  will  be 
prudent  in  the  physician  to  resume  the  lowest  dose  whenever  the 
medicine  is  prepared  by  a  different  apothecary,  or  when  the  same 
one,  having  exhausted  his  first  supply,  has  procured  another. 

A  knowledge  of  the  patient  about  to  become  the  subject  of  ex- 
periment is  the  second  and  no  less  indispensable  requisite ;  and 
we  mean  to  imply  a  knowledge  of  his  morality,  judgment  and 
susceptibility.  We  have  mentioned  morality  first,  because  when 
a  physician  tries  a  remedy  for  any  disease,  and  especially,  when 
his  first  experiments  have  acquired  some  publicity,  it  is  not  uncom- 
mon, especially  when  he  is  connected  with  an  hospital,  that  many 
persons  affected  with  the  disease  in  question  are  placed  under  his 
care;  and,  among  them,  there  are,  nearly  always,  some,  who, 
by  mistake  or  fraud,  are  not  actually  affected.  Individuals  have 
sometimes  announced  themselves  the  possessors  of  a  specific  reme- 
dy for  diseases  considered  incurable,  as,  for  example,  epilepsy  ;  and 
other  persons  associated  with  them,  have  simulated  the  disease  in 
order  to  prove  the  efficacy  of  the  medicine ;  thus  exposing  the 
public  to  double  imposition.  We  have  reason  to  believe  that  the 
seemingly  extraordinary  effects  of  magnetism  in  the  treatment  of 
disease,  and  in  the  production  of  certain  unusual  phenomena,  have 
really  been,  in  many  cases,  a  complete  deception,  in  which  one  or 
many  actors  have  played  a  part  by  no  means  creditable.  It  be- 
comes more  important  for  the  physician  who  experiments,  to  be  on 
his  guard  against  frauds  of  this  kind,  from  the  fact  that  he  is  dis- 
posed to  hope  for  certain  results  in  the  researches  in  which  he  is 
engaged,  and  eager  to  seize  upon  the  favorable  effects  of  a  remedial 
measure,  to  whose  success  he  attaches  the  double  value  of  utility 
to  suffering  humanity  and  the  advancement  of  his  own  reputation. 

There  is  another  class  of  patients  who  may  unintentionally  lead 
the  practitioner  into  error,  either  by  exaggerating  the  relief  or  the 


388  THERAPEUTICS. 

exasperation  supervening  in  their  sufferings,  or  by  attaching  to  vari- 
ous symptoms  an  importance  they  do  not  deserve,  or,  finally,  by  a 
mental  peculiarity  which  deceives  them  in  regard  to  their  actual 
condition,  some  conceiving  themselves  to  be  improving,  even  till 
the  termination  of  the  disease  in  death,  others  complaining  more 
and  more,  as  amelioration  is  more  distinctly  perceptible  and  con- 
valescence approaching  or  even  established.  These  are  evidently 
improper  persons  for  experiment.  The  same  may  be  said  of  the 
extremely  susceptible,  and  of  those  in  whom  some  idiosyncrasy 
exists;  the  organization  in  both  being  too  far  removed  from  the 
usual  conditions  to  admit  of  drawing  conclusions,  applicable  to  the 
generality  of  patients,  from  the  experiments  to  which  they  might 
be  submitted. 

To  the  most  accurate  knowledge  possible  of  the  means  to  be 
tried  and  of  the  subject  of  experiment,  that  of  the  disease  must 
necessarily  be  added.  It  is  an  indispensable  condition  in  every 
experiment,  that  there  be  no  doubt  as  to  the  diagnosis.  We  can 
readily  perceive  how  erroneous  would  be  the  results  of  experiment, 
if,  as  is  too  often  the  case,  from  the  imprudence  or  ignorance  of 
the  experimenter,  the  trials  were  made  upon  one  disease,  while  the 
conclusions  regarded  another. 

If  the  diseases  experimented  upon  had  a  determinate  duration 
and  uniform  termination  like  rabies,  the  effect  of  experimental 
measures  would  generally  be  easily  appreciated.  But  nearly  all 
diseases  are  variable  in  their  course,  of  uncertain  duration,  and 
terminate  in  different  ways.  Thus,  the  experimental  physician 
should  not  only  choose  cases  whose  diagnosis  is  unequivocal,  but, 
moreover,  his  knowledge  of  diseases  and  of  their  different  forms 
should  be  sufficiently  exact  to  enable  him  to  foresee  the  modifica- 
tions which  they  may  spontaneously  manifest,  and  their  tendencies 
to  various  terminations  :  these  are  indispensable  qualifications  for 
determining  those  of  the  supervening  phenomena  that  should  be 
attributed  to  the  remedy  under  trial,  and  those  depending  upon  the 
natural  course  of  the  disease.  We  do  not  hesitate  to  assert,  that  to 
ignorance  or  forgetfulness  of  this  truth,  most  of  the  erroneous  conclu- 
sions of  experimentalists  are  to  be  ascribed.  Nearly  all  have  referred 
the  favorable  or  unfavorable  changes,  supervening  in  diseases,  to 
the  remedy  employed.  They  have  misinterpreted  the  incessant 
action  of  the  organism  upon  pathological  phenomena,  and  have 
attributed  to  agents,  often  inert,  or  even  injurious,  those  favorable 
modifications  in  whose  production  they  had  no  part. 

The  remedy,  patient  and  disease  being  understood,  experimen- 
tation requires,  in  addition,  a  peculiar  concurrence  of  circumstan- 
ces of  more  or  less  importance. 

It  is  hardly  necessary  to  premise  that  the  therapeutical  agent 
employed  experimentally,  whether  simple  or  compound,  should  be 
uncombined  with  others.  As  has  been  remarked,  it  is  very  diffi- 
cult to  appreciate  the  action  of  a  single  remedy  upon  the  course  of 
a  disease  ;  the  simultaneous  employment  of  many  medicines,  pos- 
sessing considerable  energy,  would  render  it  almost  impossible  to 


THERAPEUTICS.  339 

decide  the  value  of  each  one  in  particular.  We  must,  moreover, 
assure  ourselves  that  the  medicine  is  used,  and  in  precisely  the 
prescribed  manner,  nothing  being  added,  removed  or  substituted. 

Another  important  point  is  to  remove,  as  far  as  possible,  from 
the  patient,  all  those  physical  and  moral  influences  capable  of 
modifying  the  course  of  the  disease,  as  well  as  the  action  of  the 
experimental  means.  Change  of  abode  and  regimen  often  suffice 
for  the  production  of  eifects  too  frequently  attributed  to  remedies : 
many  febrifuge  medicines  have  owed  their  anti-periodic  action  to 
the  circumstance  of  their  prescription  on  the  day  after  the  patient's 
entry  at  the  hospital.  What  physician  has  not  often  observed,  in 
hospitals,  in  patients  affected  with  cardiac  disease,  the  disappear- 
ance of  anasarca,  prematurely  induced  by  fatigue  or  excess  in 
food  or  drinks,  under  the  influence  of  a  few  days'  rest  and  diet ; 
and  how  many  times,  in  such  cases,  has  not  this  change,  depend- 
ing on  an  entirely  different  cause,  been  ascribed  to  remedies  wholly 
inefficacious  ? 

Atmospheric  changes  should  not  be  disregarded  by  the  experi- 
mentalist. Their  influence  upon  the  course  of  certain  affections, 
particularly  rheumatism  and  certain  neuroses,  is  well  known,  and 
should  not  be  lost  sight  of.  The  changes  supervening  in  tempera- 
ture exercise  an  influence  upon  certain  diseases,  or  upon  some  of 
their  symptoms,  easily  productive  of  erroneous  conclusions  in  re- 
gard to  the  action  of  the  remedies  employed.  By  a  repetition  of 
the  experiments  made  by  various  distinguished  physicians  upon 
the  action  of  certain  medicines  intended  to  diminish  or  suspend 
the  sweats  of  phthisis,  we  have  been  led  to  the  following  result, 
that,  giving  priority  in  the  production  of  this  symptom  to  the  alter- 
ations effected  in  the  pulmonary  parenchyma,  the  secondary  mod- 
ifications, daily  presented,  are  principally  connected  with  changes 
supervening,  either  in  the  temperature  of  the  external  air  or  of  the 
patient's  chamber,  the  position  of  his  bed,  or,  particularly,  the  con- 
tinuance of  his  sleep ;  for  the  state  of  sleep  is  a  condition  highly 
favorable  to  the  production  of  phthisical  sweats.  When  the  air 
becomes  cooler,  or  the  patient's  chamber  is  less  heated,  when  he 
lies  upon  a  mattress,  and  the  number  and  thickness  of  the  bed- 
clothes is  diminished,  and  particularly,  when  he  is  awake,  the 
means  suitable  for  subduing  these  sweats  appear  to  have  an  in- 
fluence ;  in  opposite  circumstances,  they  most  frequently  produce 
no  effect. 

It  is  equally  necessary  for  the  physician  who  experiments  to  be 
informed  in  regard  to  the  moral  circumstances  daily  surrounding 
the  individual  subjected  to  the  experiment.  When  a  disease  de- 
pends upon  profound  and  concealed  grief,  the  pharmaceutical  agent 
used  to  counteract  it  fails  to  attain  its  object;  it  is  powerless  when 
the  disease  is  exasperated  and  has  no  influence  in  its  cessation, 
still  the  physician  is  naturally  inclined  to  attribute  the  superven- 
ing changes  to  the  action  of  the  remedy  he  has  prescribed.  For 
this  reason,  it  is  the  more  important  to  obtain  the  patient's  entire 
confidence  ;  an  accurate  knowledge  of  the  disease,  as  well  as  of  the 
33* 


390  THERAPEUTICS. 

appropriate  remedies  for  its  relief  or  cure,  results  from  that  confi- 
dence. 

The  influence  of  the  imagination  upon  the  organism  is  so  great, 
that  in  a  certain  number  of  cases,  and  in  some  individuals,  the 
idea  that  a  proposed  remedy  will  cause  a  determinate  effect  has 
proved  sufficient  for  its  production.  The  case  of  an  individual 
has  been  cited,  who  was  salivated  after  taking  inert  pills,  which 
he  supposed  to  contain  mercury;  another  has  been  mentioned 
where  purging  followed  the  administration  of  a  medicine  which 
was  imagined  capable  of  producing  such  an  effect.  It  has  occa- 
sionally been  sufficient  for  the  cure  of  insomnia,  to  give  a  pill  of 
crumb  of  bread  or  of  thridace,  assuring  the  patient  that  he  would 
sleep.  How  often  has  the  progress  of  intermittent  fever,  even  of 
very  obstinate  character,  been  arrested  by  the  use  of  amulets  or 
any  other  means,  whose  action  cannot  be  other  than  imaginary. 
When,  therefore,  we  experiment  with  a  medicine,  it  is  generally 
best  that  the  patient  be  wholly  ignorant  of  the  effect  which  should 
be  produced  by  it,  so  that  imagination  may  have  no  influence  in 
the  phenomena  subsequently  supervening. 

Finally,  there  is  one  condition  among  those  capable  of  modify- 
ing the  progress  of  a  disease,  and  consequently  of  leading  to  erro- 
neous conclusions  in  regard  to  the  action  of  experimental  means, 
which  should  not  be  forgotten,  viz.  the  development  of  a  new  dis- 
ease. When  this  new  disease  is  of  an  acute  character,  there  can 
be  no  doubt  as  to  the  nature  of  this  complication  and  the  influence 
it  may  exert  upon  the  original  disease.  But  if  the  secondary  af- 
fection be  slight  and  slowly  developed,  or  if  the  patient  have  any 
motive  for  concealing  it,  it  may  thus  become  a  source  of  error  :  we 
mention  this  fact,  that  the  physician  may  never  neglect  to  inquire 
daily  into  the  condition  of  all  the  functions,  and  examine  all  the 
organs,  so  that  nothing  likely  to  be  of  service  in  the  difficult  task 
of  experimentation,  may  escape  his  observation. 

In  order  to  show  by  how  many  causes  of  error  experimentation 
is  surrounded,  we  will  give  an  abstract  of  the  trials  undertaken 
by  us  at  the  Hospital  La  Charite,  for  the  purpose  of  examining 
the  action  of  the  powdered  holly  (ilex  aquifolium),  in  the  treat- 
ment of  intermittent  fevers.  At  our  suggestion,  twenty-two  pa- 
tients were  selected  by  the  central  Office  of  admission,  for  entry 
into  the  clinical  wards,  as  affected  with  disease  of  intermittent 
nature.  Before  commencing  the  use  of  the  febrifuge,  we  were 
obliged  to  wait  several  days  for  the  complete  establishment  of 
the  diagnosis,  and  also  that  the  remedy  might  be  employed  only 
in  those  cases  where  the  paroxysms  could  neither  be  suspended 
nor  even  moderated  by  the  new  conditions  in  which  the  patients 
were  placed.  The  following  was  the  result:  of  the  twenty-two 
patients  sent  to  the  hospital,  as  affected  with  intermittent  fever, 
seven  presented  no  subsequent  paroxysm;  four  had  paroxysms 
decreasing  in  intensity ;  eight  others  manifested  merely  sympto- 
matic paroxysms,  connected  with  slight  inflammations  of  the  mu- 
cous membranes,  which  yielded  to  simple  anti-phlogistic  measures, 


THERAPEUTICS.  391 

as  cooling  drinks,  diet,  and  blood-letting ;  three  only  of  the  whole 
number  were  found  to  present  the  proper  conditions  for  experiment ; 
viz.  essential  intermittent  fever  of  full  intensity,  in  the  three  or 
four  paroxysms  succeeding  admission  to  the  hospital :  the  pow- 
dered ilex  was  administered  to  these,  at  first,  in  the  dose  recom- 
mended by  the  physician  who  had  extolled  the  remedy,  subse- 
quently, in  double,  quadruple  and  octuple  quantities,  without  any 
appreciable  effect  upon  the  progress  of  the  disease.  Sulphate  of 
quinine  was  then  given  according  to  common  practice  and  in  the 
usual  doses,  and  the  paroxysms  were  immediately  arrested.  If 
the  powdered  ilex  had  been  administered  from  the  day  of  admis- 
sion, to  all  these  patients,  or  even  to  the  fourteen  who  were  affect- 
ed with  essential  intermittent  fever,  we  should  have  been  led  to 
the  conclusion  that  the  medicine  had  acted  as  a  febrifuge  in  nine- 
teen cases  out  of  twenty-two,  or  at  least,  in  eleven  out  of  fourteen, 
and  that  the  three  cases  in  which  it  failed,  were  exceptional. 
Greater  circumspection  obtained  a  very  different  result,  viz.  that 
the  medicine  had  not  the  least  action  in  arresting  the  disease  in 
any  of  the  cases  where  it  was  properly  tried  :  it  must  be  admitted 
that  the  number  of  these  was  but  small. 

Experimentation  in  medicine,  as  in  almost  everything  else,  has 
its  advantages  and  inconveniencies.  If  experiment  were  wholly 
forbidden,  therapeutics  would  be  nearly  stationary.  Whoever 
devotes  himself  to  any  science,  should  regard  it  as  a  duty  to  do  all 
in  his  power  to  enlarge  its  domain  ;  and  when  the  object  of  this 
science  is  the  cure  of  disease  and  the  preservation  of  health,  the 
duty  becomes  even  more  imperious  and  sacred.  The  strictest  ap- 
preciation of  the  action  of  the  means  employed,  and  the  use  of 
new  means  in  the  management  of  diseases,  are  the  only  two  paths 
capable  of  conducting  to  more  positive  and  efficacious  therapeu- 
tics :  and  by  experimentation,  particularly,  taken  in  the  most 
extended  sense,  this  end  is  to  be  attained. 

That  experimentation,  whose  purpose  is  a  more  rigorous  appre- 
ciation than  has  hitherto  been  made,  of  the  action  of  the  thera- 
peutical agents  in  general  use,  or  a  determination  of  the  peculiar 
conditions  in  which  each  of  them  is  more  specially  indicated,  and 
the  proportions  in  which  it  should  be  employed,  seems  to  possess 
almost  unmixed  advantages ;  or  if  it  have  some  inconveniences, 
they  are  owing  rather  to  the  unskilful  application  of  the  means, 
than  to  experimentation  itself.  This  kind  of  experiment  is  allow- 
able in  all,  and  every  physician  who  treats  a  disease  by  common 
remedies,  should  study  their  effects,  in  order  that  each  fact  observed 
by  him  may  become,  so  to  speak,  an  element  suitable  for  the  solu- 
tion of  the  numerous  problems  presented  by  the  indefinite  perfect- 
ing of  therapeutics.  It  is  otherwise  in  that  kind  of  experimenta- 
tion which  consists  in  endeavoring  to  find,  in  new  substances, 
more  efficacious  remedies  for  the  ills  of  humanity.  Great  respon- 
sibility is  attached  to  this  species  of  experimentation,  which  is 
generally  set  apart  to  certain  individuals  who  are  prepared  for  it 
by  a  thorough  study  of  all  the  trials  of  such  nature,  previously 


392  THERAPEUTICS. 

made,  and  of  the  various  success  that  has  followed  such  experi- 
ments. 

There  are,  however,  certain  rare  circumstances  where  experi- 
ment becomes  a  duty  for  every  one ;  for  example,  when  called  to 
a  patient  affected  with  communicated  rabies,  a  disease  hitherto  con- 
stantly fatal,  should  our  efforts  be  limited  to  treating  so  terrible  an 
affection  by  the  same  means  employed  previously  without  success, 
or  should  other  remedies  be  tried,  beside  those  whose  inefficacy 
has  been  proved  ?  We  reply  unhesitatingly  that  experimentation 
is,  in  this  case,  not  only  allowable,  but  imperatively  demanded ; 
and  that  an  uncertain  remedy,  suggested  by  the  cause  and  symp- 
toms of  the  disease,  by  theory  or  empiricism,  should  be  preferred 
to  all  those  whose  insufficiency  has  been  decided. 

There  are  other  experiments  not  allowable  in  any  one:  we 
mean  those  made  with  the  intention  of  assisting  the  diagnosis  of  a 
disease  considered  contagious,  by  inoculating  persons  apparently 
disposed  to  contract  it.  In  some  cases,  for  example,  where  doubt 
had  existed  in  regard  to  the  nature  of  certain  varioliform  erup- 
tions, inoculation  of  the  secretion  of  the  pustules  has  been  pro- 
posed, and  even  tried  upon  persons  who  had  never  had  variola 
nor  been  vaccinated.  A  prudent  and  conscientious  physician  will 
never  allow  himself  to  make  such  experiments,  because  it  is  not 
for  the  benefit  of  the  individual  submitted  to  them,  and  the  human 
being  should  never  be  an  object  of  experiment  for  the  physician, 
even  when  the  interests  of  science  and  humanity  are  the  object, 
and  the  greatest  advantages  might  be  expected  for  both. 

A  single  experiment,  whatever  be  the  result,  cannot  establish 
the  general  efficacy  of  any  therapeutical  measure.  Doubtless,  it 
would  be  a  very  remarkable  event,  if  the  symptoms  of  rabies  were 
suspended  in  a  single  case  where  a  new  remedy  was  tried ;  a 
unique  fact,  even,  of  this  nature,  would  be  a  very  important  result, 
particularly  if  from  the  circumstances  antecedent  to,  and  the  ac- 
companying phenomena  of  the  disease,  it  were  evident  that  the 
affection  was  really  rabies,  and  not  one  of  those  varieties  of  hydro- 
phobia too  often  mistaken  for  it.  But  even  in  this  case,  new  ex- 
periments would  be  necessary,  in  order  to  form  a  correct  opinion  of 
the  effect  of  the  experimental  remedy  ;  still  more  necessary  is  it  to 
repeat  the  trials  before  a  final  conclusion,  if  the  disease,  instead  of 
inevitably  terminating  in  death,  when  left  to  itself,  like  rabies, 
be  susceptible  of  various  terminations.  We  cannot,  therefore,  de- 
rive satisfactory  results  from  experimentation,  except  when  the 
disease,  influenced  by  the  experimental  remedy,  terminates  favor- 
ably in  a  larger  majority  of  cases,  or  in  a  shorter  time,  than  under 
any  other  treatment;  from  this  arises  the  necessity  of  uniting  the 
greatest  possible  number  of  cases,  taken  from  different  sources,  that 
is,  collected  by  different  observers,  in  various  times  and  places, 
and  of  comparing  arid  counting  them,  in  order  to  attain  as  positive 
results  in  therapeutics  as  in  etiology  and  semeiology.  This  con- 
clusion leads  us  to  declare  our  opinion  of  the  numerical  method, 
applied  to  the  study  of  diseases. 


THERAPEUTICS.  393 

The  enumeration  of  previously  collected  cases,  the  deduction  of 
accurate  results  from  their  comparison  and  number,  either  in  re- 
gard to  the  predisposing  or  determining  causes  of  the  disease,  or  its 
characteristic  phenomena,  course  and  different  terminations,  or, 
finally,  as  respects  the  influence  of  therapeutical  means,  constitutes 
no  innovation  in  medicine.  Many  historians  of  epidemic  diseases 
have  adopted  this  course ;  they  have  stated  the  population  of  the 
place  where  the  epidemic  prevailed,  the  number  of  those  attacked, 
and  also  that  of  each  sex,  of  children,  adults  and  aged  persons,  and 
the  proportionate  mortality  in  these  various  divisions.  In  Bayle's 
work  on  Pulmonary  Phthisis,  in  nearly  all  the  French  and  foreign 
yearly  clinical  recapitulations,  etc.,  in  our  own  thesis  upon  rheum- 
atism, in  1813,  and  in  various  memoirs  read  by  us  either  before 
the  Institute,  upon  the  use  of  sulphate  of  quinine,  or  to  the  Acad- 
emy of  Medicine  upon  the  powder  of  ilex  aquifolium  in  intermit- 
tents.  this  mode  of  presenting  general  results  is  employed  as  a 
means  of  arriving  at  those  more  exact,  without  any  one  having 
imagined  it  improper  to  draw  numerical  conclusions  from  a  com- 
parison of  cases  previously  collected.  It  was  at  that  period,  only, 
when  Louis,  the  most  accurate  and  conscientious  observer  of  our 
times,  thought  it  right  to  apply  this  method,  in  its  highest  degree  of 
development,  to  the  solution  of  many  pathological  questions,  to 
which  the  collision  of  opinions  and  the  ardor  of  controversy  had 
given  great  importance,  that  this  mode  of  deducing  consequences 
from  facts  was  attacked,  both  individually  and  in  its  applications, 
with  a  vivacity,  inexplicable,  except  by  calling  to  mind  the 
antecedent  contest.  In  the  heat  of  the  discussion  that  arose  in  the 
Royal  Academy  of  Medicine,  certain  orators  arrived  at  this 
direct  conclusion,  that  every  enumeration  of  pathological  facts  was 
essentially  opposed  to  sound  logic,  and  could  not  furnish  other 
than  erroneous,  and  consequently,  dangerous,  results ;  from  thence 
they  argued  an  absolute  proscription  of  this  method,  to  which  the 
appellations  numerical  method  or  medical  statistics  have  been  ap- 
plied. Without  desiring  to  resume  and  retrace,  in  all  its  details,  a 
discussion,  in  regard  to  which  there  is  still  a  difference  of  opinion, 
we  deem  it  proper  to  examine  the  main  arguments  employed 
against  the  enumeration  of  facts :  and  to  reply  to  whatever  they 
may  contain  that  is  plausible. 

In  order  to  examine  this  subject  methodically,  we  remark  first, 
that  in  the  enumeration  of  medical  facts,  there  are  two  points, 
wholly  distinct,  and  both  requiring  particular  study.  While  col- 
lecting a  large  number  of  cases,  comparing  them  together  in  all 
their  different  aspects,  making  numerical  tables  of  everything  re- 
lating to  their  causes,  symptoms,  progress,  duration,  various  ter- 
minations, and  the  influence  of  the  different  curative  means  em- 
ployed, the  physician  is  but  an  exact  historian  of  actual  facts,  and 
if  narrations  of  this  sort  are  uninteresting,  they  cannot  be,  and 
never  have  proved,  (we  will  not  say  dangerous)  even  incon- 
venient. Let  us  suppose  that  two  physicians,  equally  truthful,  and 
gifted  with  the  same  spirit  of  observation,  both  give  an  account  of 


394  THERAPEUTICS. 

an  epidemic  which  they  have  observed  together ;  also,  that  the 
first,  in  his  description,  states  the  precise  number  of  inhabitants  in 
the  city  or  village  where  the  disease  prevailed,  the  number  of  per- 
sons affected,  both  those  sufficiently  so  to  require  confinement  to 
bed,  and  those  who,  being  less  ill,  are  able  to  pursue  some  of  their 
occupations ;  that  he  gives,  in  addition,  the  number  of  infants, 
adults,  and  aged  persons,  and  of  males  and  females  ;  the  proportion 
of  patients  engaged  in  various  occupations  ;  the  duration,  in  days, 
of  the  disease  in  these  different  circumstances ;  the  rate  of  mortality 
in  each ;  and  let  this  recapitulation  be  supported  by  observations 
made  upon  each  of  these  patients  during  the  course  of  the  epi- 
demic. Let  the  other  physician,  on  his  part,  relate  the  results  of 
his  observation  during  the  disease,  as  faithfully  as  his  memory  will 
allow,  but  without  any  use  of  numbers,  expressing  himself  thus, 
for  instance ;  in  a  city  rather  densely  populated,  a  considerable 
proportion  of  the  inhabitants  were  attacked  by  the  epidemic,  which 
was  more  fatal  among  males  than  females  ;  its  course  was  gener- 
ally acute,  its  termination  fatal  in  a  large  number  of  patients,  etc. ; 
we  should  not  hesitate  to  pronounce  the  latter  account  very  far 
inferior  to  the  former,  and  we  should  be  justified  in  doubting  its 
correctness  when  compared  with  the  other,  even  allowing  for  the 
vagueness  of  the  expressions  employed.  We  are,  in  truth,  so 
easily  prepossessed  by  the  first  cases  that  impress  us,  and  so  in- 
clined to  draw  general  conclusions  from  our  first  ideas,  that  we 
need  the  uncompromising  addition  of  numerous  facts  to  confirm 
or  rectify  our  original  opinion.  It  has  often  happened  to  M.  Louis 
and  myself,  when  observing  together  the  same  patients,  at  the 
Hospital  La  Charite,  to  arrive  at  a  conclusion,  whose  inaccuracy 
was  subsequently  proved  by  a  numerical  recapitulation  of  the 
same  cases.  It  is,  then,  useful  to  count  the  complete  cases,  and 
the  number  of  times  their  development  has  been  preceded  by  a 
certain  cause,  or  that  a  certain  symptom  has  appeared  in  the  course 
of  the  disease,  also  to  enumerate  the  days  of  its  duration,  and  the 
number  of  favorable  or  unfavorable  terminations ;  and  however 
great  may  be  the  antipathy  of  certain  physicians  to  numbers,  we 
cannot  suppose  that  it  can  be  carried  so  far  as  to  reject  the  numer- 
ical statement  of  complete  cases ;  this  would  be  a  rejection  of  ac- 
curacy, and,  consequently,  of  truth. 

However  true  a  proposition  may  be,  it  may  always,  for 
want  of  good  reasons,  be  attacked  by  specious  arguments.  Thus, 
it  has  been  objected  that  every  numerical  relation  is  not  exempt 
from  errors,  and  that  the  apparent  accuracy  imparted  by  numbers, 
renders  it,  for  that  very  reason,  more  dangerous  than  ordinary 
narration.  We  willingly  admit  that  every  problem  in  addition  is 
not  necessarily  exact,  whether  it  be  applied  to  pathological  facts  or 
to  anything  else  whatever ;  that  one  may  calculate  erroneously  in 
medicine  as  in  other  matters  ;  it  should  be  added  that  it  is  the  duty 
of  those  who  accept  a  calculation,  to  verify  it.  But,  it  will  be 
said,  if  the  calculation  rest  upon  incomplete,  inexact  or  prejudiced 
observations,  what  a  multitude  of  errors  will  be  the  result !  The 


THERAPEUTICS.  395 

reply  is  easy ;  the  numerical  method  is  not  in  fault,  but  the  obser- 
vations that  have  served  as  a  foundation  for  the  calculation.  If, 
therefore,  it  be  attempted  to  conclude  that  a  measure  should  be 
renounced  because  improperly  employed,  observation  itself  must 
be  resigned,  under  the  pretext  that  there  are,  in  medicine,  as  in 
nearly  all  sciences  based  upon  observation,  as  many  and  more, 
bad,  than  there  are  good,  observers. 

If  the  numerical  method  had  had  no  other  object  than  to  ascer- 
tain everything  relating  to  complete  cases,  it  would,  doubtless, 
never  have  aroused  the  violent  discussions  that  have  occurred. 
But  in  medicine,  as  all  are  aware,  the  past  is  the  instructor  of  the 
present ;  in  the  most  thorough  and  accurate  knowledge  possible  of 
complete  cases,  all  that  the  physician  should  know,  may,  and 
ought  to  be  discovered,  as  the  causes  of  diseases,  the  signs  that 
characterize  them  or  announce  their  tendency  towards  a  favora- 
ble or  unfavorable  termination,  and  the  proper  means  for  their 
relief  or  cure.  The  numerical  method,  while  it  renders  the  study 
of  thoroughly  observed  cases  more  precise,  as  a  natural  conse- 
quence, elucidates  all  the  branches  of  pathology  and  particularly 
therapeutics ;  the  controversy  relates  to  these  various  questions, 
and  we  shall  examine  it  in  connection  with  them. 

Among  the  numberless  objections  that  have  been  raised  against 
the  numerical  method  as  applied  to  pathology,  some  regard  the 
method  itself,  and  others  the  improper  use  that  has  been  or  might 
be  made  of  it.  The  latter  class  of  objections  are  nearly  valueless  ; 
it  can  only  be  considered  a  kind  of  warning  against  the  errors 
liable  to  be  induced  by  any  method  of  studying  cases  and  draw- 
ing conclusions  from  them,  in  all  the  natural  sciences  as  well  as  in 
medicine.  Observation  itself  is  quite  as  obnoxious  to  these  ob- 
jections as  is  a  method  which  may  be  termed  the  logic  of  the 
sciences :  with  such  axioms  to  commence  with,  we  should  be  for- 
bidden to  observe,  under  the  pretext,  that  bad  observation  is  dan- 
gerous; not  only  should  figures  be  banished  from  reasoning  pro- 
cesses, but  reasoning  itself,  however  conducted,  should  share  their 
fate,  because  unskilful  logic  leads  directly  to  error.  Without 
doubt  there  is  both  inconvenience  and  danger  in  numerical  con- 
clusions drawn  from  facts  badly  observed,  not  sufficiently  numer- 
ous, intentionally  selected  as  more  favorable  to  certain  systematic 
opinions,  falsified  or  imaginary ;  the  evil,  however,  would  be  still 
greater  if  this  recapitulation  'of  cases,  without  foundation  upon 
actual  facts,  were  but  a  deceptive  assertion  uttered  in  defence  of  a 
theory.  But  would  the  fault  be  ascribable  to  a  method  which  re- 
quires accuracy  and  truth,  as  fundamental  conditions,  both  in  the 
facts  themselves,  and  in  the  consequences  resulting  from  their  com- 
parison and  enumeration?  These  first  objections,  then,  do  not 
deserve  a  serious  reply,  for  they  are  not  peculiar  to  the  numerical 
method,  but  apply  equally  to  all  the  other  modes  of  scientific 
procedure  and  reasoning ;  all,  without  exception,  will  lead  us  into 
error  if  there  be  carelessness  or  deception  in  those  who  collect  and 
compare  the  cases,  and  unthinking  credulity  in  those  who  receive 


396  THERAPEUTICS. 

them.  We  may  add,  that  if  the  distinction  between  truth  and 
error  be  frequently  difficult,  it  is  not,  at  least,  beyond  the  power  of 
the  human  mind;  and  that  in  intellectual,  as  in  moral  affairs,  it  is 
possible  to  attain,  by  effort,  the  knowledge  of  the  truth.  In  the 
case  at  present  under  consideration,  it  is  doubtless  quite  difficult  to 
distinguish  the  observer  worthy  of  confidence  from  him  who  is  not 
so;  and  also  to  determine,  among  the  numerous  observations  daily 
added  to  those  of  former  days  and  ages,  those  that  bear  the  im- 
press of  truth ;  but  the  physician  who  associates  a  correct  judg- 
ment with  the  habit  of  observing  nature,  generally  acquires  the 
power  of  ascertaining  the  degree  of  confidence  merited  by  men  and 
things.  Admitting,  even,  that  inaccurate  or  even  fictitious  reca- 
pitulations may  have  momentarily  misled  physicians  upon  any 
one  point  in  our  science,  new  observations  and  conscientious  re- 
views will  soon  furnish  opposite  results :  from  this  arises  the 
necessity,  for  all  observers,  of  collecting  facts  bearing  upon  the 
same  question,  and  these  should  also  be  numerous,  in  order  to  at- 
tain, by  force  of  numbers,  more  positive  conclusions ;  upon  this 
depends  the  triumph  of  truth.  Thus,  if  the  faulty  employment  of 
the  numerical  system  have  introduced  errors  into  science,  the  same 
method,  and  that  alone,  skilfully  and  conscientiously  employed, 
will  definitively  re-establish  the  truth.  Passing  over  these  objec- 
tions, we  hasten  to  consider  those  relating  to  the  actual  enumera- 
tion of  cases,  and  not  to  any  want  of  conscientiousness  or  judg- 
ment in  those  who  employ  it. 

It  should  be  remarked,  in  the  first  place,  that  those  who  do  not 
collect  exact  observations,  nor  note  down  facts  which  they  observe, 
and  who,  after  a  certain  number  of  years  of  study  and  practice, 
are,  consequently,  unable  to  state  the  sum  of  these  facts,  and  still 
less,  to  know,  in  each  separate  observation,  the  numerical  expres- 
sion of  each  condition  presented  by  the  disease,  as  regards  causes, 
signs  and  effect  of  remedies ;  who  have  not  thus  added  up  the 
whole,  in  order  to  have  the  exact  sum  total,  adopt,  nevertheless, 
as  the  result  of  their  observations  and  the  rule  of  their  practice,  an 
approximate  total,  which,  if  they  possessed  the  necessary  elements 
for  testing  its  accuracy,  would,  perhaps,  be  very  far  from  true. 
They  wish  to  count  approximatively,  to  add  without  figures,  and  to 
draw  conclusions  from  this  exceedingly  imperfect  calculation,  but 
they  will  have  no  numbers ;  yet  who  can  deny  the  value  of  num- 
bers, wherever  applied  ?  Those  who  have  grown  old  in  our  pro- 
fession possess  an  authority  mainly  dependent  upon  the  number  of 
facts  they  have  observed ;  for  this  reason  their  advice  is  sought 
and  followed  by  younger  physicians,  in  serious  and  difficult  cases; 
from  this,  also,  arises  that  public  consideration  and  confidence 
particularly  attaching  to  physicians  who,  arrived  at  mature  age, 
and  entrusted  with  hospital  practice,  have  been  favorably  placed 
for  the  observation  of  a  larger  number  of  cases  and  the  acquisition 
of  greater  experience :  numbers  may,  then,  be  considered  impor- 
tant in  medicine,  and  even  those  who  do  not  employ  the  nu- 
merical system  would  not  fail  to  say,  in  a  discussion  with  a 


THERAPEUTICS.  397 

younger  physician,  c  We  have  observed  such  a  fact  more  frequently 
than  you  have  ;  such  an  occurrence  is  more  common  than  another ; 
such  a  disease  has  appeared  to  us  to  be  often,  or  nearly  always, 
favorably  modified  by  a  certain  remedy,'  etc.  Doubtless  this  is 
not  enumeration,  properly  speaking,  but  it  is  a  species  of  count- 
ing; for,  when  affirming  that  a  certain  occurrence  is  more  frequent 
than  another,  there  must  be  some  recollection  of  the  number  of 
times  that  each  of  the  facts  has  been  observed  ;  there  must  be  an 
approach  to  addition,  subtraction  and  conclusion.  He  who  would 
disregard  the  number  of  facts  observed  by  him,  could  not  do  it;  he 
would  be  led  to  keep  account  of  them  in  spite  of  his  efforts,  as  if 
by  unavoidable  necessity.  The  power  of  facts  depends  especially 
upon  their  repetition,  and  it  is  impossible  for  the  mind  to  disregard 
their  number.  Every  physician,  therefore,  computes,  consciously 
or  otherwise,  properly  or  improperly,  the  facts  he  observes,  and 
experience  in  medicine  implies  the  collection  of  a  large  number  of 
cases,  accurately  or  approximative^  counted. 

Every  one  is  aware  that  the  antagonists  of  the  numerical  system 
are  not  opposed  to  approximative  enumeration,  but  to  the  exact  ad- 
dition of  facts  and  figures.  When  an  observer,  acknowledged  by 
them  in  other  respects  to  be  accurate  and  conscientious,  commences 
the  addition  of  the  cases  he  has  collected  and  the  deduction  of  the 
numerical  consequences  resulting  from  their  collation,  they  reg;ard 
the  procedure  as  a  faulty  method,  both  derogatory  to  the  physician, 
and  communicating  the  worst  and  most  dangerous  direction  to 
scientific  pursuit !  An  absurd  mode  of  reasoning  indeed,  is  that 
which  allows,  on  identical  subjects,  an  approximative  and  more 
or  less  inaccurate  calculation,  while  it  forbids  those  characterized 
by  the  strictest  accuracy  !  We  shall,  however,  review  the  argu- 
ments upon  which  these  conclusions  have  been  founded. 

"The  numerical  method,"  it  has  been  said,  "leads  to  the  substitu- 
tion of  calculation  for  reasoning,  and  of  arithmetic  for  induction." 
There  is  not  the  least  foundation  for  such  a  reproach  ;  far  from 
excluding  the  reasoning  process  from  medicine,  the  numerical  re- 
sults furnished  by  the  collection  and  comparison  of  a  large  number 
of  cases  give  to  reasoning  a  more  secure  foundation  and  a  truer  di- 
rection, and  preserve  it  from  the  errors  too  often  arising  when  it  is 
based  upon  facts  too  few  in  number  or  imperfectly  analyzed  and 
counted.  In  our  opinion,  the  numerical  method  is  the  most  suit- 
able system  possible  for  reinstating'  reasoning  in  favor  with  those 
physicians,  who,  considering  only  the  mistakes  into  which  sys- 
tematic authors  have  too  often  been  led  by  faulty  logic,  would  wil- 
lingly have  proscribed  the  use  of  the  reasoning  powers  in  medi- 
cine for  the  sake  of  preventing  their  abuse  ! 

One  of  the  most  plausible  objections  to  the  enumeration  of 
pathological  facts,  is,  indisputably,  the  difficulty  of  uniting  similar 
facts  in  order  to  deduce  from  them  general  consequences.  The 
same  disease  presents  such  a  variety  of  forms,  that  perhaps  it 
never  occurs  twice  with  a  perfect  similarity.  But  the  infinite 
variety  of  forms  existing  in  animals  of  the  same  species,  or  in  the 
34 


398  THERAPEUTICS. 

leaves  of  the  same  tree,  does  not  prevent  us  from  distinguishing, 
notwithstanding  the  slight  dissimilarity  observed  in  these  various 
natural  products,  the  species  to  which  they  belong,  because  the 
fundamental  characteristics  possessed  by  them,  in  common,  are  far 
more  evident  than  the  shades  of  difference  they  exhibit.  The 
same  is  true  in  pathology,  as  has  been  fully  established  by  M. 
Rayer,  and  diseases,  when  divided  into  genera,  species  and  va- 
rieties,* may  be  easily  compared  and  enumerated,  thus  affording 
exact  conclusions.  Let  it  be  supposed,  for  example,  that  in  all  the 
cases  of  mild  tertian,  of  herpes  zoster,  variola  discreta  or  confluens, 
acute  pneumonia,  lenticular  cataract,  furunculus,  and  erysipelas  of 
the  face,  the  disease  is  developed  in  individuals  previously  in  good 
health  and  of  adult  age ;  we  then  have  a  collection  of  cases  that 
may  be  compared,  and  susceptible  of  furnishing,  by  this  process, 
numerical  results  presenting  many  points  of  interest.  We  would, 
moreover,  ask  those  physicians  who  derive  their  antipathy  for 
figures  from  the  dissimilarity  of  diseases,  if  this  want  of  resem- 
blance be  not  quite  as  much  an  obstacle  to  general  descriptions  of 
diseases  as  to  the  enumeration  of  isolated  facts.  If,  therefore, 
those  physicians  who  have  written  upon  general  pathology,  have 
not  been  arrested  in  their  labors  by  the  infinite  dissimilarities  that 
cannot  have  escaped  their  notice ;  if  their  descriptions  be  con- 
sidered not  only  useful,  but  indispensable,  in  the  study  of  medi- 
cine ;  if  many  authors  owe  the  high  reputation  heretofore  and  at 
present  accorded  to  them  in  the  medical  world,  to  researches  of 
this  nature  ;  why  should  hindrances  be  thrown  in  the  way  of  the 
partisans  of  statistical  medicine,  when  every  one  sees  the  necessity 
of  avoiding  them,  and  which,  without  any  compensation,  would 
reduce  medicine  to  its  condition  in  primitive  times,  that  is,  to  a 
mere  collection  of  isolated  observations  inscribed  successively  upon 
daily  records,  like  those  upon  the  columns  "of  the  ancient  temples? 
The  idea  that  no  conclusions  should  be  drawn  from  pathological 
facts,  except  so  far  as  they  present  a  complete  identity,  (an  iden- 
tity not  to  be  found  in  nature,)  is  a  blind  assumption  which  should 
be  condemned  by  good  sense  and  the  power  of  facts. 

"Disease,"  it  has  been  remarked,  "being  composed  of  various 
elements,  cannot  be  subjected  to  calculation  like  a  single  phenome- 
non." —  "  The  advocates  of  statistics,"  it  has  been  added,  "  while 
they  enumerate  all  the  details  of  disease,  separate  its  elements 
from  one  another  into  so  many  different  divisions  that,  subse- 
quently, it  is  impossible  to  reconstruct  the  disease." 

Thus,  according  to  one  class  of  objectors,  the  numerical  method 
is  inapplicable  to  pathological  studies,  because  it  considers  a  thing 
essentially  complex  as  a  unique  phenomenon,  and,  according  to 
others,  because  it  examines,  singly,  each  constituent  element  of  the 
disease.  Although  these  two  objections  antagonize  one  another,  as 


*  See  the  chapters  entitled,  "  The  different  Genera,  Species  and  Varieties  of 
Diseases  "  ;  and  "  Diagnosis." 


THERAPEUTICS.  399 

it  were,  as  it  is  possible  that  one  of  them  may  have  some  founda- 
tion, we  deem  it  proper  to  examine  both. 

We  have  previously  declared  disease  to  be  complex  in  its  na- 
ture. Therefore,  whenever  the  numerical  method  is  applied  to 
the  study  of  any  disease,  it  is  absolutely  necessary,  as  we  have  al- 
ready remarked,  to  divide  the  cases  into  as  many  groups  as  the 
diversity  of  its  assumed  forms,  or  the  various  conditions  in  which 
it  is  manifested,  may  require.  The  enumeration  and  comparison 
of  the  cases  comprised  in  these  separate  groups  supply  us  with 
conclusions  which  are  always  interesting,  whether  they  are  or 
not,  in  accordance  with  generally  admitted  opinions.  Not  only 
has  care  always  been  taken,  in  the  application  of  the  numerical 
method  to  the  study  of  disease,  to  subdivide  the  particular  cases 
according  to  their  analogies,  but,  moreover,  the  elementary  con- 
ditions of  these  subdivisions  have  been  separately  examined,  as, 
for  example,  the  causes,  duration,  termination  and  action  of  differ- 
ent remedial  means.  There  is,  perhaps,  no  numerical  collection 
hitherto  published  that  does  not  contain  all  these  details.  How 
then  can  we  imagine  it  possible  that  statistical  medicine  should  be 
reproached  with  considering  a  disease  as  a  unique  phenomenon? 
The  opposite  objection  is  less  surprising,  viz.,  the  subdivision  of 
diseases  to  an  extent  rendering  it  impossible  to  reunite  their  ele- 
ments. This  objection  is,  however,  more  specious  than  real,  and 
is  quite  as  easily  refuted  as  the  other.  The  authors  of  nosographi- 
cal  works  of  any  extent,  after  having  described  the  disease  gener- 
ally, have  nearly  always  considered  the  chief  characteristic 
symptoms  separately,  as,  for  instance,  in  pneumonia,  the  pain  in 
the  side,  dyspnoea  and  sputa,  and  have  pointed  out  the  different 
degrees  of  intensity  and  the  other  varieties  presented  by  these 
symptoms.  They  have  also  devoted  separate  articles  to  the  exam- 
ination of  some  of  the  causes  and  of  the  modus  operandi  of  certain 
remedies.  The  same  is  done  by  means  of  the  numerical  system  ; 
the  details,  it  is  true,  are  not  so  interesting,  because  they  are  ex- 
pressed in  figures  only;  but,  in  reality,  as  we  cannot  examine 
each  element  of  a  disease  collectively,  we  are  compelled,  whatever 
be  the  method  employed,  to  examine  them  successively ;  whether 
it  be  into  articles  or  columns,  by  means  of  words  or  figures,  they 
must  be  separated,  or  if  the  expression  be  preferred,  scattered 
(eparpiller)  ;  and  we  cannot  see  that  the  re-collection  of  the  ele- 
ments of  the  disease,  if  deemed  necessary,  is  more  difficult  in  one 
case  than  the  other. 

It  has,  moreover,  been  asserted,  "  that  statistics  tend  to  establish 
fixed  modes  of  treatment."  If  medical  statistics,  resting  upon  nat- 
ural bases,  could  lead  to  the  result,  that,  in  a  given  disease,  a  cer- 
tain treatment  would  be  constantly  followed  by  more  complete  and 
rapid  success  than /any  other,  we  should  be  obliged  to  confess,  that 
science  would  derive  therefrom  very  decided  benefit.  But  from 
the  great  accuracy  it  gives  to  the  cases  subjected  to  its  application, 
it  is  quite  unlikely  that  it  will  ever  attain  such  a  result.  It  will, 
more  probably,  lead  to  an  exposition  of  the  more  or  less  numerous 


400  THERAPEUTICS. 

exceptions  to  those  general  precepts  which  the  mind  is  but  too 
readily  disposed  to  establish  and  accept,  when  computation  is  not 
employed  :  the  evident  mission  of  the  numerical  system  is  to  de- 
stroy these  illusions. 

It  has,  moreover,  been  advanced  that  "  this  method  disregards 
minorities  and  exceptions."  If  we  admit  that  a  certain  fact  is  of 
so  general  occurrence  that  there  is  but  one  exception  in  a  hundred 
cases,  the  enumerator  will  be  obliged  to  record  the  proportion  in 
figures,  thus,  1  and  99 ;  while  he  who  never  computes,  impressed 
by  the  frequency  of  the  fact  in  question,  will  readily  conclude  that 
it  is  constant.  He  who  never  adds  cases  together  may  easily  and 
conscientiously  forget  minorities,  while  the  physician  who  employs 
the  numerical  method  is  obliged  not  only  to  consider  the  exceptions 
but  to  give  their  number. 

"  The  most  useful  therapeutical  axioms  have  been  discovered 
without  the  aid  of  statistics."  The  object  of  statistics  is  not,  and 
cannot  be,  discovery,  in  the  common  acceptation  of  the  word:  its 
purpose  is  to  verify  discoveries,  appreciate  the  value  of  opinions, 
and  occasionally  to  reveal  general  truths  previously  unknown,  but 
not  to  imagine  or  invent.  If,  therefore,  the  assertion  that  nearly 
all  the  valuable  truths  in  therapeutics  have  been  discovered  with- 
out the  assistance  of  statistics,  be  correct,  it  should  also  be  remem- 
bered, that  there  is  decidedly  no  process  so  prompt  and  sure  for 
confirming  or  disproving  general  therapeutical  precepts,  as  the 
numerical  method. 

"  The  physician  must  be  guided  at  the  bedside  of  the  patient  by 
the  knowledge  of  indications  alone,  and  not  by  statistics."  To 
this  objection  we  reply  by  the  following  questions :  What  is  the 
basis  of  the  knowledge  of  indications  ?  How  is  it  known  that  a 
certain  case  requires  blood-letting,  and  another,  cinchona  or  fer- 
ruginous compounds?  Is  it  by  theoretical  opinion  only,  or  because 
experience  has  shown  the  utility  of  these  several  means  in  cases 
similar  to  those  under  observation?  What  constitutes,  moreover, 
the  basis  of  experience?  Is  it  not* founded  upon  observations  and 
experiments  sufficiently  numerous  to  establish  the  therapeutical 
action  of  various  agents ;  and  are  not  statistics  thus  proved  to  be 
the  strength  of  that  very  science  of  indications  which  has  been 
cited  as  in  entire  opposition  to  them  ? 

One  of  the  most  serious  objections  raised  against  medical  statis- 
tics is  that  of  M.  Gavarret,  whom  we  are  far  from  considering  an 
opponent  of  the  system.  "  However  numerous,"  says  he,  "may 
be  the  facts  collected  for  the  purpose  of  attentively  examining  any 
point  in  medicine,  we  may  still  infer,  that  if  the  number  had  been 
greater,  the  statistical  results  would  not  have  been  the  same,  and 
that  if  the  same  observer  had  continued  his  researches  for  a  longer 
time  before  enumerating  the  cases,  he  would  have  arrived  at  differ- 
ent conclusions." 

It  should  be  remembered  that  the  numerical  method  is  applicable 
only  to  complete  cases ;  and  that,  assuming  the  principle  stated  by 
M.  Gavarretj  the  application  of  enumeration  must  be  indefinitely 


THERAPEUTICS.  401 

suspended,  because  the  collection  of  a  million  of  cases  even,  would 
give  results  which  might  be  modified,  however  slightly,  by  a  com- 
parison of  double  that  number.  Admitting  such  a  principle,  and 
applying  it  in  its  full  extent,  all  general  description  must  be 
abandoned :  for  the  reunion  of  a  larger  number  of  facts  would 
modify  that  also.  Doubtless  it  may  be  advantageous,  and  even 
necessary,  to  include  in  numerical  summaries  the  greatest  possible 
number  of  analogous  cases;  but  this  consideration  should  not  re- 
tard indefinitely  the  enumeration  of  those  observed.  As  we  have 
previously  seen,  the  progress  of  science  would  thus  be  impeded, 
from  an  exaggerated  apprehension  lest  it  should  wander  from  the 
true  path. 

We  remark,  moreover,  that  the  numerical  system  has  not,  and 
cannot  have,  the  pretension  of  fixing,  from  the  present  moment, 
the  laws  of  our  science,  or  of  establishing  limits  beyond  which  the 
mind  will  find  nothing  to  discover  or  rectify.  The  observer  who 
publishes  a  number  of  cases,  compares  them  and  deduces  from 
them  numerical  consequences,  by  no  means  pretends  that  a  recom- 
mencement of  the  same  task  is  superfluous ;  far  from  this,  he  en- 
courages all,  by  example  and  precept,  to  follow  the  same  course, 
convinced  that  the  truth  can  only  gain  thereby,  either  from  the 
entire  confirmation  of  the  results  he  has  obtained,  by  new  obser- 
vations, or  that  from  the  collection  and  comparison  of  new  facts, 
conclusions  more  or  less  at  variance  with  his  own  may  be  obtained. 

It  should,  however,  be  remarked,  that  it  is  not  always  indis- 
pensable that  a  considerable  number  of  cases  be  collected,  in  order 
to  obtain  interesting  results  and  conclusions,  which,  in  all  proba- 
bility, will  be  confirmed  by  time.  When  a  physician  who  de- 
votes himself  to  observation  makes  a  numerical  review,  at  the 
years  end,  of  those  diseases  whose  history  he  has  recorded,  and  by 
comparing  the  results  of  the  succeeding  with  those  of  preceding 
years,  ascertains,  that  upon  certain  points  in  etiology,  diagnosis  or 
therapeutics,  the  numerical  conclusions  are  uniformly  the  same,  it 
is  very  probable,  to  use  no  stronger  expression,  that  the  constant 
occurrences  of  each  of  the  past  years  will  likewise  characterize 
those  which  are  to  come.  Supposing,  also,  that  an  observer  does 
not  commence  computation  until  after  a  long  time  devoted  to  the 
collection  of  cases,  as,  for  example,  ten  years,  and  that,  having, 
in  the  first  place,  collected  and  computed  all  the  facts  relating  to  a 
given  disease  in  one  general  table,  and  analyzed  their  separate 
elements,  he  next  subdivide  his  observations  into  yearly  tables, 
still  finding  that  the  proportions  in  the  single  years  correspond 
with  those  of  the  general  table,  and  consequently  resemble  each 
other;  such  a  constant  reproduction  of  the  same  facts,  for  ten  con- 
secutive years,  will  certainly  allow  of  drawing  conclusions,  which, 
although  not  absolute,  will  be  very  valuable. 

A  final  objection  against  the  numerical  method 'is,  "that  it  leads 
to  the  use  of  fictitious  averages,  which  are  useless  in  pathology  and 
therapeutics."     In  the  first  place,  we  will  acknowledge  that  a  de- 
ceptive application  of  these  averages  may  be  made ;  that  if,  for 
34* 


402  THERAPEUTICS. 

example,  in  collecting  a  considerable  number  of  facts  relating  to 
pneumonia,  (a  disease  infinitely  more  serious  from  the  second  to  the 
fifth  year,  and  after  the  sixtieth,)  and  endeavoring  to  establish  the 
mean  age  in  fatal  cases,  the  ages  of  children  and  old  persons  were 
confounded  in  one  enumeration,  a  mean  age  would  result  quite 
evidently  incorrect  and  in  glaring  contradiction  with  the  very  i'acts 
upon  which  it  was  founded.  Age  has  so  great  an  influence  upon 
the  result  of  the  disease,  that  it  is  absolutely  necessary  to  study 
pneumonia  in  each  of  the  vital  periods  and  obtain  the  average 
mortality  peculiar  to  each.  The  same  process  is  required  when 
the  duration  of  any  disease  is  considered,  as  of  acute  articular 
rheumatism ;  if  many  groups  be  not  made,  of  which  one  shall  in- 
clude the  greatest  number  of  cases  whose  average  duration  is  from 
fifteen  to  eighteen  days ;  another,  the  exceptional  cases,  where  the 
duration  is  much  less  or  far  greater,  there  will  result  a  mean  con- 
tinuance which  will  be  insufficient  and  will  not  indicate  the  limits 
within  which  the  varieties  of  the  disease  are  comprised.  The  same 
is  true  when  we  would  determine,  not  only  by  the  numerical,  but  by 
any  other  method,  the  doses  in  which  it  is  proper  to  administer  the 
various  remedies  :  several  average  doses  should  be  established,  one 
of  which  will  apply  to  the  greatest  number  of  individuals  and  the 
others  to  the  rarer  cases,  where  the  dose  of  the  remedy  should  be 
increased  or  diminished  according  to  the  age  and  susceptibility  of 
the  patients,  and  the  obstinacy  and  severity  of  the  disease.  This 
supposes,  indeed,  numerous  facts,  collected  with  great  care  and 
judiciously  compared ;  but,  whatever  method  be  adopted  in  the 
practice  of  medicine,  are  not  these  conditions  indispensable  in  order 
to  obtain  accurate  conclusions? 

In  concluding  this  discussion,  doubtless  too  long  continued,  and 
which  we  should  not  have  undertaken  if  its  actuality  had  not 
made  it  imperative,  will  a  deliberate  answer  be  expected  to  the 
singular  charge,  that  the  numerical  method  would  detract  from  the 
consideration  in  which  physicians  are  held,  either  by  rendering  them 
all  equal,  or  by  lowering  their  qualifications  beneath  those  of  the 
most  obscure  artisan?*  Does  then  the  numerical  method,  by 
furnishing  a  more  solid  foundation  for  the  conclusions  drawn  from 
particular  cases  observed  in  all  ages  and  .places,  by  adding  new 
general  facts  to  those  already  belonging  to  science,  by  offering  an 
additional  means  of  distinguishing  truth  from  error,  diminish  the 
importance  of  the  physician  ?  And  will  the  science,  which,  of 
all  others,  demands  the  greatest  perseverance  in  its  researches,  em- 
bracing so  extensive  a  range  of  knowledge  that  the  powers  of  the 
human  mind  and  an  entire  life  are  hardly  sufficient  for  its  acqui- 
sition, requiring  so  much  sagacity  and  circumspection  in  its  appli- 
cations, descend  to  the  lowest  rank  in  the  scale,  from  the  moment 

*  "  If  the  numerical  method  were  adopted,  it  whould  place  all  physicians  upon 
an  equality. —  If  therapeutics  were  to  be  regulated  by  the  computations  of  the 
adherents  of  statistics,  there  would  be  more  skill  in  the  trade  of  a  cobbler  than  in 
the  practice  of  medicine." — (Seance  de  TAcaddmie  Roy  ale  de  Mtdecine,  du%5 
Ai-nl  1837  et  suit-antes.) 


THERAPEUTICS.  403 

when  a  surer  method  is  interposed  for  the  appreciation  of  the  facts 
upon  which  it  is  based?  If  the  numerical  method  tends  to 
equalize  all  physicians,  by  reducing  the  most  difficult  of  the  arts 
to  certain  rules  so  simple  and  clear  that  the  most  limited  intelli- 
gence suffices  for  their  application,  far  from  being  proscribed,  it 
should  be  ranked  above  all  that  the  human  mind  has  ever  con- 
ceived that  is  useful  and  wonderful.  Let  those  be  encouraged, 
however,  who  so  much  fear  an  equality,  the  very  idea  of  which 
offends  them.  Medicine,  in  its  imperfect  development,  will  always 
present  an  unlimited  field  to  the  practitioner,  where  numberless 
obstacles  will  be  encountered,  and  in  which  talented  minds  will 
show  their  power  and  superiority. 

Having  examined  each  of  the  principal  objections  to  the  appli- 
cation of  the  numerical  method  to  pathological  facts,  we  think  it 
may  be  concluded  that  this  system  must  lead  to  eminently  useful 
results,  provided  it  be  founded  upon  observations  entirely  correct 
and  sufficiently  numerous,  that  no  more  be  expected  from  it  than 
it  can  give,  and  that  the  necessary  accuracy  and  discrimination  be 
employed  in  its  application. 

The  length  of  the  discussion  into  which  we  have  been  led, 
obliges  us  to  return  to  the  point  where  it  was  commenced.  Hav- 
ing established  the  principle  that  therapeutics  are  based,  on  the 
one  hand,  upon  a  profound  knowledge  of  the  natural  tendencies  of 
diseases  to  various  terminations,  and  on  the  other,  upon  the  proper 
means  for  opposing  or  encouraging  these  tendencies,  we  added, 
that  observation  and  experience  were  alone  able  to  direct  us  in 
this  double  study.  We  have  pointed  out  the  conditions  necessary 
for  accurate  observation  and  the  principal  rules  for  experimentation 
in  medicine,  which  led  us  to  discuss  the  application  of  the  numerical 
method  to  pathology.  We  return  to  our  starting-point,  that  is,  ex- 
perience, considered  as  a  basis  of  therapeutical  science. 

Experience  should  not  be  confounded  with  experiments  (experi- 
ences) ;  the  latter  are  to  the  former  as  the  materials  to  the  edifice. 
When  the  influence  of  a  certain  therapeutical  agent  upon  the  pro- 
gress of  a  given  disease  has  been  ascertained  by  numerous  experi- 
ments, its  effects  are  then  sanctioned  by  experience.  Thus,  the 
power  of  cinchona  over  intermittents,  and  the  influence  of  diet  in 
acute  diseases,  is  established  by  experience.  This  experience  is 
accurately  transmitted  from  age  to  age,  both  by  tradition  and 
books ;  it  belongs  to  no  individual,  but  to  the  science  itself. 

There  is  another  kind  of  experience  which  is  differently  trans- 
mitted ;  it  is  that  acquired  by  the  physician ;  it  belongs  to  him, 
and  dies,  almost  entirely,  with  him.  Zimmermann*  defines  it  to  be 
the  art  of  preserving  the  human  body  from  the  diseases  to  which  it 
is  exposed,  and  of  treating  it  when  actually  laboring  under  disease ; 
it  results  from  the  observations  of  each  physician  in  particular. 
In  order  to  possess  this  experience,  much,  and  particularly  accu- 
rate, observation  is  necessary. 

*  ZIMMERMANN,  de  VExperience,  t.  i.  p.  22. 


404  THERAPEUTICS. 

If  the  talent  for  observation  were  equal  in  all,  experience  might 
be  estimated  by  the  number  of  years,  according  to  the  vulgar 
standard,  but  it  is  so  variously  distributed,  that  age  cannot  be 
considered  an  indication  of  the  degree  of  experience.  Every  year 
adds  to  the  experience  of  some  physicians,  while  the  longest  life  is 
insufficient  to  impart  it  to  others. 

The  physician's  private  experience,  it  has  been  said,  dies  with 
him,  because  there  are  certain  things  of  which  he  judges  instinct- 
ively, and  for  which  he  cannot  himself  account,  much  less  com- 
municate them  to  others.  We  do  not  adopt  this  opinion.  Admit- 
ting that  there  are  some  impressions  with  difficulty  accounted  for 
by  the  physician,  and  which  are  yet  more  difficult  of  expression 
and  transmission,  we  still  think  that,  in  these  very  cases,  the 
physician  can  and  ought  to  discover,  by  attentive  examination 
and  active  analysis  of  the  past  circumstances  and  existing  phe- 
nomena of  the  disease,  the  reasons  for  his  diagnosis  and  his  con- 
sequent determinations ;  these  reasons  once  ascertained,  there  can 
be  no  real  hindrance  to  their  expression.  We  should  not,  then, 
consider  this  power  of  forming  instinctive  opinions  as  the  result  of 
long  experience  ;  it  is  only  the  proof,  either  of  the  habit  of  incom- 
plete observation  of  pathological  phenomena,  or  of  an  indolent 
mind  that  does  not  apply  itself  sufficiently  to  the  scrutiny  of  their 
value.  In  our  opinion,  an  enlightened  and  conscientious  phy- 
sician should  know  how  to  avoid  these  vague  conclusions  andbe 
able  to  communicate  his  own  experience  to  those  who  observe  his 
daily  practice.  This  direct  transmission  constitutes  what  is  termed 
traditionary  medicine,  which  is  the  most  useful  form  of  instruction, 
and  renders  evident  that  very  remarkable  and  well  known  dif- 
ference existing  between  physicians,  who,  during  their  term  of 
preparatory  study,  have  seen  much  hospital  practice,  and  those 
who  have  gathered  all  their  information  in  theoretical  courses  and 
from  books.  Attendance  on  the  medical  visits  of  distinguished 
physicians  is  the  most  suitable  means  for  the  rapid  acquisition  of 
experience  by  the  student.  It  has  been  justly  remarked,  "Medi- 
cine cannot  be  learned  except  by  association  with  physicians  and 
patients ;  the  physician  cannot  be  self-formed ;  an  experienced 
guide  is  necessary,  without  whom,  the  student  loses  his  way 
among  the  various  systems,  or  becomes  an  empiric."  *  Tradition 
is  so  highly  important  in  the  practice  of  medicine,  that  there  is, 
perhaps,  no  example  of  a  skilful  practitioner  who  has  not  enjoyed 
the  instructions  of  an  experienced  teacher.  In  medicine,  as  in  all 
practical  arts,  there  are  many  hints  of  more  or  less  value  communi- 
cated by  the  physician  to  those  who  observe  his  practice,  and 
which  could  not  be  otherwise  transmitted.  When  an  intelligent 
and  well  instructed  student  has  followed  any  practitioner  for  a 
certain  time,  he  can  nearly  always  announce,  after  examining  a 
patient,  riot  only  what  treatment  his  instructor  will  adopt,  but  even 
the  remedial  formulae  he  will  prescribe.  What  work  could  give 

*  Essai  historique  sur  la  Medecine  en  France,  by  /.  B.  L.  Chomel.  Paris,  1762. 


THERAPEUTICS.  405 

us  such  accurate  knowledge,  and  who  can  flatter  himself  that  he 
could  tell  what  Fernel  or  Boerhaave  would  have  prescribed  in  a 
given  case  ? 

Observation  and  experience  serve  as  guides  in  the  treatment  of 
diseases  only  by  the  aid  of  the  reasoning  powers.  This  it  is  which 
points  out  the  analogy  between  various  affections  and  leads  the 
physician  to  apply,  in  his  own  practice,  the  means  that  have 
proved  beneficial  in  that  of  others.  Reasoning  cannot,  then,  be 
proscribed  in  medicine,  as  blind  empiricism  would  advise ;  *  but 
the  only  kind  that  should  be  employed,  as  Sydenham  has  ju- 
diciously remarked,  is  simple  and  natural  reasoning,  derived  from 
good  sense  and  apparently  the  immediate  consequence  of  the  facts 
observed.  Whenever  a  course  of  treatment  is  resolved  upon  after 
a  long  series  of  arguments  more  or  less  ingeniously  linked  together, 
errors  are  almost  inevitably  committed,  equally  injurious  to  the 
physician  and  dangerous  to  the  patient. 

Some  have  endeavored  to  substitute  other  foundations  for  thera- 
peutical science  than  observation  and  experience  aided  by  natural 
reasoning  ;  the  physical  and  chemical  theories  have  led  t;  eir  parti- 
sans to  advocate  the  possibility  of  establishing  the  treatment  of 
diseases  upon  a  new  basis.  Natural  philosophy  is  useful  in  some 
of  its  applications  to  a  certain  number  of  affections,  particularly 
mechanical  lesions.  An  exact  comparative  analysis  of  the  fluids 
and  solids,  both  in  disease  and  health,  with  that  of  the  remedies 
employed,  may  likewise  furnish,  in  certain  cases,  important  indica- 
tions. For  example,  when  a  chemical  agent  introduced  into  the 
stomach  causes  toxicological  symptoms,  we  may,  while  the  poi- 
sonous substance  is  still  contained  in  the  digestive  canal,  endeavor 
to  neutralize  it  by  means  of  the  reagents  designated  by  chemistry. 
When  the  urinary  passages  contain  concretions  of  uric  acid,  the 
use  of  alkaline  remedies  may  dissolve  them  and  consequently  pro- 
cure their  expulsion.  In  diabetes  mellitus,  while  the  concurrence 
of  chemistry  is  requisite  in  tracing  the  changes  that  supervene  in 
the  proportion  of  the  saccharine  principle,  several  useful  indications 
are  also  furnished  by  it  for  the  treatment,  in  regard  to  the  choice 
of  alimentary  substances  the  least  likely  to  furnish  the  elements  of 
sugar.  But  with  the  exception  of  a  few  diseases,  chemistry  is  but 
of  slight  service  in  therapeutics,  and  the  error  of  those  chemists 
who  compare  the  human  body  to  an  inert  vase,  wherein  they  sepa- 
rate, precipitate  or  disengage  the  constituent  principles  of  inorganic 
bodies  or  of  organized  substances  no  longer  subject  to  vital  laws, 
has  been  too  long  refuted  to  require  any  opposition  on  our  part. 

*  "An  empiric  in  medicine  is  one,  who,  totally  disregarding  the  operations  of 
nature,  the  signs  and  causes  of  diseases,  the  indications,  methods,  and,  particu- 
larly, the  discoveries  of  different  ages,  merely  asks  the  name  of  the  disease  and 
administers  his  drugs  at  hazard,  or  mechanically,  following  his  routine  and  mis- 
understanding the  science.  His  experience  is  always  deceptive,  because  he  prac- 
tices ignoramly  and  follows  the  prescriptions  of  others  without  inquiring  into 
their  causes,  essence  or  purpose."  —  ZIMMERMANN,  Traitt  de  rExptrience,  t.  i. 
p.  19. 


406  THERAPEUTICS. 

We  have  endeavored  to  give  an  accurate  idea  of  therapeutical 
science  ;  we  have  examined  its  foundations ;  its  applications  will 
be  next  considered. 

Therapeutical  science  may  be  naturally  divided  into  two 
branches ;  to  the  first  belong  the  indications ;  to  the  second,  the 
means  for  their  fulfillment. 


ARTICLE  FIRST. 
Indications. 

WHEN  the  physician  has  discovered,  by  attentive  examination  of 
the  patient,  the  kind  of  disease  with  which  he  is  affected,  its  pecu- 
liar character,  progress,  tendency  to  favorable  or  unfavorable  ter- 
mination, its  productive  causes,  influence  upon  the  health,  etc., 
these  united  circumstances  show  the  method  of  treatment  to  be 
pursued,  and  apparently  indicate  it :  this  is  termed  indication.  It 
has  been  also  defined  to  be  the  manifestation,  furnished  by  the 
disease  itself,  of  the  treatment  likely  to  ameliorate  the  patient's 
condition. 

Indications  should  never  be  established  upon  theory  or  abstract 
reasoning ;  they  should  spring,  as  it  were,  from  the  phenomena  of 
the  disease,  and  present  themselves,  unsought  for,  to  him  who  has 
become  acquainted  with  all  the  concomitant  circumstances.  It  is 
rarely  necessary,  and  often  dangerous,  to  seek  for  indications  when 
they  are  not  present :  we  are  liable  to  imagine  their  existence,  and 
to  misunderstand  those  which  afterwards  supervene  in  reality ;  at 
the  bedside  alone,  and  in  proportion  to  the  development  of  the  dis- 
ease, can  they  be  distinguished  and  apprehended ;  with  this  sig- 
nification, the  following  axiom,  taken  from  an  art  very  different  in 
its  results,  but  analogous  in  its  principles,  has  been  applied  to  med- 
icine by  a  celebrated  physician  :  *  "  We  should  take  counsel  in  the 
arena  (consilium  in  arena,  sumere)" 

There  is  a  certain  number  of  circumstances  in  disease  capable  of 
supplying  indications.  The  principal  are  the  kind  of  disease,  its 
peculiar  form,  its  intensity,  its  type  and  its  periods.  The  state  of 
the  strength,  the  predominant  symptoms,  seat,  complications, 
causes  and  certain  commemorative  circumstances,  the  tendency  of 
the  disease  to  various  terminations,  the  influence  it  may  exert  upon 
the  patient's  constitution,  or  upon  pre-existing  affections,  the  effect 
of  previously  employed  means,  either  in  the  case  in  question  or  in 
others,  and  during  epidemics,  furnish  indications  which  should  not 
be  neglected;  we  shall  give  a  brief  explanation  of  these  indi- 
cations. 

A.  The  genus  of  the  disease  is  the  most  influential  of  all  the 
conditions  from  which  indications  are  derived.  The  approxima- 
tion of  the  edges  of  a  wound,  the  coaptation  of  fractured  bones, 

*  DuMOULIN. 


THERAPEUTICS.  407 

restoration  of  displaced  organs  to  their  natural  position,  mainte- 
nance of  an  inflamed  part  in  complete  rest,  and  of  a  position  the  least 
likely  to  induce  stagnation  of  the  blood,  the  removal  of  everything 
which  might  increase  the  pain ;  blood-letting  in  pneumonia,  the 
administration  of  cinchona  in  intermittent  fevers,  and  of  mercury 
in  syphilis,  are  each,  in  these  various  diseases,  the  first,  as  well  as 
the  most  important,  indication.  Pathological  anatomy  concurs  also 
in  furnishing  very  important  indications,  by  revealing  the  seat  of  a 
large  number  of  diseases  and  the  peculiar  changes  wrought  by 
them  in  the  tissues  of  our  organs.  In  many  cases,  however,  other 
indications  occur,*  which  should  not  only  be  considered,  but  may 
even  exceed  in  importance  those  derived  from  the  genus  of  the 
disease. 

B.  The  peculiar  character  of  the  disease  is  of  great  importance 
in  regard  to  treatment.     There  are  many  acute  affections  which 
uniformly  tend,  of   themselves,  when  regular  in   their  progress 
(maladies  ligitimes),  to  a  favorable  termination,  and  consequently 
need  no  active  treatment ;  while  energetic  means  are  required  when 
they  are  of  inflammatory  or  adynamic  character,  etc.     In  such 
cases  the  principal  indications  arise  from  the  character  of  the  dis- 
ease, and  those  furnished  by  the  genus  are  only  of  secondary  value. 
This  is  observed  in  erysipelas,  bronchitis,  and  the  morbillous  erup- 
tion, when  manifested  in  one  of  the  forms  previously  mentioned. 

C.  Very  important  indications  are  supplied  by  the  type  of  the 
disease.     Experience  having  proved  that  all  regularly  periodical 
diseases  are  susceptible  of  arrest  by  peculiar  treatment,  it  is  of  the 
greatest  consequence  that  the  intermittent  type  be  distinguished 
when  present,  and  advantage  taken  of  the  valuable  indication  it 
affords,  especially  in  the  malignant  form  of  these  diseases.     The 
patient's  life  is.  here  in  the  physician's  hands ;  if  he  neglect  the 
offered  indication,  death  is  nearly  inevitable ;  if  he  fulfil  it  prompt- 
ly, health  may  almost  always  be  restored.     The  different  intermit- 
tent types  give  rise  also  to  some  secondary  indications  ;  the  shorter 
the  interval  between  the  paroxysms,  the  more  energetic  should  be 
the  treatment;  this  becomes  far  more  necessary  when  the  paroxysms 
approach  still  nearer  and  the  type  tends  to  the  continued  form.   In 
certain  irregularly  intermittent  diseases,  it  has  been  stated  that  by 

*  We  deem  it  proper  to  quote  the  very  judicious  reflections  of  Laennec  upon  this 
subject :  "I  think  that  the  study  of  pathological  specimens  is  the  only  base  of 
positive  knowledge  in  medicine,  and  that  it  should  never  be  lost  sight  of,  unless  we 
would  pursue  chimeras  and  create  phantoms  merely  for  the  purpose  of  contending 
with  them  .  .  .  But  I  also  consider  it  equally  dangerous  to  give  so  excluive 
an  attention  to  the  study  of  local  affections,  as  thereby  to  lose  sight  of  the 
different  causes  on  which  they  may  depend,  or,  in  other  terms,  their  evident  or 
obscure  nature.  The  necessary  inconveniences  arising  from  so  restricted  a  mode 
of  study  are  an  assumption  of  the  effect  for  the  cause  and  exposure  to  the  still 
more  serious  error  of  considering  as  identical,  diseases  in  which  the  only  visible 
alterations  are  lesions  anatomically  resembling  each  other,  and  treating  them  all 
similarly. 


408  THERAPEUTICS. 

attentive  observation  of  the  reproductive  causes  of  the  attacks,  their 
return  has  been  regulated,  and  the  specific  remedies  subsequently 
administered  with  advantage ;  but  it  must  be  confessed,  that  the 
action  of  cinchona  in  diseases  artificially  rendered  periodical,  is 
not  so  well  established  as  in  natural  intermittents.  For  this  reason, 
we  cannot  place  entire  confidence  in  the  ingenious  method  em- 
ployed by  Professor  Dumas  of  Montpellier,  who,  in  a  case  of  epi- 
lepsy, first  rendered  the  attacks  regular,  and  then  administered 
cinchona. 

D.  The  state  of  the  vital  forces  is  decidedly  one  of  the  most 
important  indications.  Whatever  be  the  genus  of  an  affection,  its 
species  or  its  type,  it  is  of  as  much  and  even  more  consequence  to 
diminish  excessive  vital  action  and  to  sustain  it  when  too  far  de- 
pressed, as  to  treat  the  disease;  on  this  account,  it  is  indispensable 
that  the  physician  keep  constantly  in  view,  and  attentively  com- 
pare, the  probable  length  and  the  violence  of  the  disease,  with  the 
strength  of  the  patient*  He  should  be  particularly  on  his  guard 
against  debility,  which  might  either  cause  the  patient's  death  before 
the  usual  period  of  termination  of  the  affection,  or  embarrass  the 
series  of  phenomena  or  the  necessary  efforts  for  the  re-establish- 
ment of  the  functions.  This  indication  becomes  so  urgent  that  it 
should,  when  life  seems  nearly  extinct,  supersede  all  the  rest,  and 
lead  to  the  employment  of  the  appropriate  means  for  supporting 
vitality,  even  in  affections  which  seem  to  call  for  remedies  of  an 
entirely  opposite  character,  as  in  pneumonia,  for  example,  or  any 
other  phlegmasia  :  the  ancients  styled  this  the  vital  indication. 

The  estimation  of  the  vital  powers  in  disease  constitutes,  there- 
fore, one  of  the  most  interesting  points  in  practical  medicine. 
Nearly  all  therapeutical  systems  have  been  based  upon  the  division 
of  diseases  into  sthenic  and  asthenic,  active  and  passive ;  and  in  a 
considerable  number  of  cases,  the  principal  question  is  to  know 
whether  the  treatment  should  be  tonic  or  debilitant.  It  is,  then,  of 
the  greatest  importance  to  determine  the  signs  by  which  the  vital 
force  may  be  estimated,  especially  in  acute  diseases,  where  all  delay 
is  dangerous  and  error  causes  very  serious  consequences. 

It  should  be  remembered  that  such  an  estimate  of  the  powers  of 
life  is,  in  a  certain  number  of  cases,  very  obscure  and  difficult;  to 
be  convinced  of  this,  we  only  need  to  glance  at  the  divisions  estab- 
lished by  Brown,  and  also  at  those  substituted  for  them  by  authors, 
who,  like  Broussais,  were  led  to  adopt  an  analogous  division, 
founded  upon  opposite  principles.  The  same  affections  are  enu- 
merated, in  one  of  these  systems,  among  those  characterized  by 
excess,  which  in  the  other  are  marked  by  diminution  of  vital 
action.  The  same  obscurity  may  perplex  us  at  the  bedside,  and  it 
has  sometimes  happened  that  cinchona  has  been  advised  by  one 
physician  for  the  same  patient,  in  whose  case  another  had  pre- 

*  Galen  compared  the  patient  to  a  man  carrying  a  burden,  the  disease  to  the 
burden,  and  its  duration  to  the  distance  to  be  traversed  by  the  bearer. 


THERAPEUTICS.  409 

scribed  blood-letting.  It  is,  however,  but  jnst  to  say,  that  such 
difference  of  opinion  is  hardly  ever  manifested  except  among  sys- 
tematic physicians,  and  that  there  is  scarcely  an  example  among 
skilful  observers,  accustomed  to  collect  all  the  information  that  can 
aid  them,  before  resolving  upon  any  mode  of  treatment. 

There  are  many  physicians  who  estimate  the  state  of  the  vital 
powers  almost  entirely  by  the  pulse;  if  this  be  full  and  resistant, 
they  are,  according  to  them,  necessarily  in  excess.  The  most  vio 
lent  partisans  of  the  doctrine  of  irritation  have  gone  still  farther; 
the  frequency  of  the  pulse,  which  in  acute  diseases  increases  with 
the  debility  and  is  never  greater  than  in  the  death-struggle,  was 
for  them  a  sign  of  excessive  vital  action,  or,  what  is  the  same  thing, 
an  indication  for  the  employment  of  the  antiphlogistic  treatment. 
Others  have  adopted,  as  a  criterion,  the  energy  of  the  movements, 
the  color  of  the  face,  or  the  strength  of  the  constitution ;  certain 
others,  the  pale  or  deep  color  of  the  urine ;  many,  the  state  of 
the  general  heat ;  others,  finally,  the  power  with  which  the  heart 
contracts.  Many  of  these  signs  are  certainly  highly  important  in 
the  estimation  of  the  vital  forces,  and  none  should  be  neglected ; 
but  doubtless,  also,  each  of  them  when  isolated  from  the  rest  is 
insufficient.  If  examples  were  necessary  to  prove  this,  we  might 
cite  the  weakness  of  the  pulse  in  certain  inflammations  accompa- 
nied with  severe  pain ;  its  hardness,  persisting  even  till  death,  in 
certain  cases  of  hypertrophy  of  the  heart ;  the  sensation  of  general 
coldness  at  the  commencement  of  the  most  acute  phlegmasiae  ;  and 
the  convulsive  movements  succeeding  profuse  haemorrhage.  But 
we  need  not  insist  upon  a  doctrinal  point,  upon  which  all  experi- 
enced practitioners  are  agreed,  viz. :  that  in  the  estimation  of  the 
vital  forces,  all  the  signs  likely  to  express  their  degree  should  be 
taken  into  consideration. 

The  vital  powers  may  be  modified  in  various  ways  in  disease ; 
they  are  augmented,  diminished,  suspended,  perverted  or  oppressed. 
They  may  also  present  no  evident  disturbance,  as  is  occasionally 
observed  in  diseases  limited  to  one  organ,  and  which  do  not,  ap- 
parently, disturb  the  others. 

Increase  of  the  vital  forces  is  generally  characterized  by  a  lively 
red  color  of  the  skin,  redness  and  intumescence  of  the  face,  regular 
and  confident  movements,  full  respiration,  strong  pulse,  increased 
heat,  firmness  of  the  muscles,  marked  diminution  of  the  excretions, 
particularly  of  the  urine  and  fasces,  and  that  amendment  which  su- 
pervenes in  the  symptoms  after  spontaneous  haemorrhage.  The 
blood  is  observed  to  be  of  firm  consistence  and  a  vermilion  color,  and 
contains  a  greater  proportion  of  fibrine  arid  corpuscles.  These  phe- 
nomena are  rarely  observed  united  in  the  same  individual ;  in  their 
different  combinations  and  intensity  they  present  very  various 
gradations,  either  in  different  patients  or  in  the  course  of  the  same 
affection;  they  are,  generally,  far  more  strongly  marked  at  the 
outset  of  the  disease  and  in  the  paroxysms,  than  during  the  remis- 
sions or  towards  the  decline. 

Diminution  of  the  vital  forces  is  denoted  by  pallor  of  the  cutane- 
35 


410  THERAPEUTICS. 

ous  surface,  shrinking  of  the  features,  languor  in  the  attitude  and 
motions,  fain  tings,  frequency  and  feebleness  of  respiration,  weak 
pulse,  diminished  heat,  sensitiveness  to  cold,  flabbiness  of  the  mus- 
cles, arid  the  abundance  and  tenuity  of  the  excretions.  If  haemor- 
rhage occur  under  these  circumstances,  the  other  signs  become 
thereby  more  manifest,  and  the  effused  blood  is  paler  in  color  and  less 
consistent  than  in  health.  — Diminished  vital  action  may  assume 
various  forms  ;  in  some  acute  diseases,  it  may  become  quite  decided 
in  a  few  days  ;  it  is  then  evidenced  by  collapsed  features,  pale  skin, 
difficulty  or  impossibility  of  maintaining  the  erect  or  even  the  sit- 
ting posture,  diminution  of  heat,  cold  sweats,  involuntary  excre- 
tions, deliquium  animi  and  syncope.*  These  signs  are  usually 
more  distinct  during  the  remission ;  they  are  veiled,  as  it  were, 
by  the  transient  excitement  constituting  the  paroxysms ;  conse- 
quently, we  here  observe  the  contrary  of  that  which  happens 
when  the  vital  force  is  in  excess,  and  where  the  sthenic  character 
of  the  disease  becomes  more  marked  in  the  exacerbations.  There 
are,  however,  some  affections  in  which  the  debility  becomes  more 
decided  in  the  actual  paroxysms ;  this  occurs  in  many  varieties  of 
malignant  fevers,  as  the  syncopal  form,  [a  variety  of  intermittent 
in  which  there  are  one  or  more  fainting  fits  in  every  paroxysm. 
Dunglison.  —  Med.  Diet.  A  form  of  frequent  occurrence,  —  death 
is  almost  inevitable  after  a  second  paroxysm.  Grisolle.  Path.  Int. 
vol.  i.  p.  149.]  and  febris  algida  :  [algor,  cold,  — a  pernicious  in- 
termittent accompanied  by  icy  coldness,  often  fatal  in  the  second 
or  third  paroxysm.  Op.  sup.  cit.  —  TR.]  :  diminution  of  the  vital 
forces,  which  is  hardly  noticed  during  the  intermissions,  is  at  its 
extreme  in  the  paroxysms.  In  chronic  diseases,  debility  super- 
venes but  slowly  ;  its  principal  indicatory  signs  are  emaciation  of 
the  whole  body,  but  particularly  of  the  face,  increasing  difficulty  of 
motion,  rapidly  induced  fatigue  resulting  from  bodily  or  mental 
exercise,  feebleness  of  the  pulse,  sensitiveness  to  external  cold, 
sometimes  oedema  of  the  cellular  tissue,  and  passive  sanguineous 
exhalation  from  different  parts  of  the  body ;  it  rarely  attains  such 
a  degree  that  it  prevents  patients  from  moving  in  bed,  as  happens 
in  many  acute  diseases. 

Complete  suspension  of  the  vital  phenomena,  in  syncope,  con- 
gelation and  asphyxia,  indicates  a  momentary  abolition  or  suspen- 
sion of  the  vital  forces. 

*  The  terms  defaillance  and  syncope  are  considered  synonymous  by  Dunglison 
and  some  others,  but  Nysten  (Med.  Diet.)  points  out  the  shade  of  difference  be- 
tween them  which  is  also  implied  in  the  text  (See,  also,  p.  115.)  Def alliance, 
which  we  have  rendered  deliquium  animi,  is  the  first  stage  of  syncope  and  might 
be  aptly  designated  fainting,  consisting  'as  it  does  in  the  sudden  diminution  of 
the  heart's  action,  progressively  continuing,  with  greater  or  less  rapidity,  until  the 
syncopal  state  is  fully  attained,  or  else  arrested  by  remedial  means  previously  to 
complete  syncope.  Lipothymia  is  characterized  by  the  persistence  of  respiration 
and  circulation,  sensation  and  motion  being  only  diminished;  syncope,  by  entire 
suspension  (usually  momentary,)  of  sensation,  motion,  respiration  and  circulation 
(syncope  confirmee.  Grisolle.  Path.  Int.  vol.  ii  p.  UU7,  ^d  edit.).  The  dis- 
tinction seems  highly  appropriate.  —  TRANS. 


THERAPEUTICS.  411 

Perversion  of  the  vital  forces  is  denoted  by  a  more  or  less  mani- 
fest change  in  the  union  or  succession  of  those  phenomena  con- 
sidered capable  of  indicating  their  measure:  at  one  time  it  is 
the  simultaneous  existence  of  symptoms  not  generally  observed 
united,  at  another,  a  rapid  succession  of  phenomena  opposed  to  one 
another,  and  still  more  frequently,  sympathetic  disturbance  of  the 
cerebral  functions,  particularly  the  intelligence,  sensations,  ex- 
pression of  countenance,  gestures  and  movements.  Perversion  may 
co-exist  with  augmentation  and  diminution  of  the  vital  forces,  or 
be  manifested  singly.  From  this  arises  the  difficulty  of  perceiving 
the  indications  in  these  embarrassing  cases,  and  the  disagreement 
of  authors  and  practitioners  upon  this  important  point  in  thera- 
peutics. 

Oppression  of  the  vital  forces  *  is  that  state  in  which  there  is 
apparent  diminution,  but  actual  augmentation  of  the  forces;  it  is 
manifested,  indeed,  by  phenomena  nearly  resembling  those  char- 
acteristic of  diminished  vital  force,  as  collapsed  features,  pallor  or 
lividity  of  the  face,  difficult  motion,  torpor  of  the  senses  and  intel- 
lectual faculties,  feebleness  and  sometimes  inequality  of  the  pulse, 
coldness  of  the  extremities,  etc.  In  such  cases,  we  must  refer  to 
antecedent  circumstances  in  order  to  appreciate  the  actual  state  of 
the  forces.  Real  debility  almost  always  arises  from  evident  causes, 
existing  in  individuals  naturally  feeble,  or  weakened  by  excessive 
fatigue  of  body  or  mind,  by  prolonged  grief,  privation  of  food,  or 
the  ingestion  of  that  but  slightly  nutritive,  excessive  evacuations, 
watching,  and  the  abuse  of  physical  pleasures.  Oppression  of  the 
forces,  on  the  contrary,  occurs  particularly  in  strongly  constituted 
individuals  of  mature  age,  who  are  high  livers  or  even  epicures  ;  it 
takes  place  suddenly,  at  the  invasion,  or  at  least  in  the  first  period 
of  diseases,  while  real  debility  is  observed,  generally,  to  be  pro- 
gressive and  to  occur  in  a  later  stage.  In  obscure  cases,  where 
nothing  that  may  elucidate  should  be  neglected,  the  color  and 
consistence  of  the  blood  effused  in  haemorrhage  or  drawn  by  vene- 
section, leeches  or  cupping  glasses,  the  peculiar  aspect  of  wounds 
and  blisters,  and  the  qualities  of  the  pus  secreted  and  discharged 
by  them,  deserve,  also,  the  physician's  attention.  Another  very 
suitable  means  for  ascertaining  the  state  of  the  forces  is  observa- 
tion of  the  changes  supervening  in  the  intensity  of  the  disease, 
either  from  the  effect  of  the  first  remedies  employed  or  from  other 
circumstances.  If  debilitants,  and,  particularly,  blood-letting, 
have  procured  relief;  if  spontaneous  haemorrhage  or  alvine  evacu- 
ations seem  to  diminish  the  debility,  oppression  of  the  forces  doubt- 
less exists.  If.  on  the  other  hand,  spontaneous  or  artificial  evacu- 
ations have  proved  injurious,  if  wine  and  cordials  have  moderated 
the  intensity  of  the  disease,  the  diminution  of  the  forces  is  real, 

*  Oppression  of  the  forces  is  that  condition  at  the  commencement  of  the  phleg- 
masiee,  fevers,  &c.,  in  which  the  system  is  oppressed  rather  than  debilitated  :  the 
patient  is  embarrassed  by  excess  of  the  vital  forces  (Nysten,  Diet.  Medecine)  : 
vascular  action  rises,  as  the  obstruction  to  free  circulation  is  relieved  by  bleeding, 
purging,  ^c.  (Dunglison.) — TRANS. 


412  THERAPEUTICS. 

and  the  physician  should  act  accordingly.  Another  sign,  to  which 
the  greatest  importance  was  attached  by  Laennec,  should  be  added 
to  the  above  ;  this  is  the  contractile  power  of  the  heart.  Accord- 
ing to  this  physician,  "  whenever  the  ventricular  contractions,  (as 
appreciated  by  auscultation,)  are  energetic,  we  may  abstract  blood 
fearlessly ;  the  pulse  will  rise ;  but  if  the  cardiac  contractions  be 
feeble,  even  though  the  pulse  retain  a  certain  force,  we  should  ab- 
stain from  depletion."  In  obscure  cases,  this  suggestion  should 
not  be  neglected,  although  the  phenomenon  does  not  possess  the 
value  attributed  to  it  by  Laennec ;  the  force  with  which  the  heart 
contracts,  depending  quite  as  much  upon  the  anatomical  conditions 
pertaining  to  the  organ,  as  on  the  general  state  of  the  vital 
forces.  In  persons  affected  with  hypertrophy  of  the  heart,  its 
contractions,  as  well  as  the  arterial  pulsations,  continue  with  extra- 
ordinary power,  even  to  the  moment  of  death ;  in  others,  on  the 
contrary,  the  heart  contracts  feebly,  although  all  the  other  indi- 
cations are  those  of  excessive  vital  action  and  demand  depletion.  * 
Such  are  the  principal  circumstances  by  means  of  which  the 
state  of  the  vital  forces  in  disease  may  be  estimated  ;  they  cannot 
solve  all  the  questions  arising  upon  so  delicate  and  important  a 
point  in  practical  medicine  ;  but  they  may  assist  the  physician  in 
ordinary  cases,  a  knowledge  of  which  is  the  most  important.  It 
should  be  added,  before  concluding  this  article,  that  the  appreciation 
of  the  forces  is  sometimes  so  difficult,  that  the  most  experienced 
physician  is  obliged  to  withhold  his  opinion,  and  refrain,  for  a  time, 
from  any  active  treatment,  that  he  may  not  proceed  at  random. 

E.  The  intensity  of  the  disease  is  likewise  a  source  of  useful  in- 
dications.   Not  that  the  same  affection  may  require  opposite  treat- 
ment, according  as  it  is  severe  or  otherwise  ;  but  there  is  so  great  a 
difference  between  the  indications  in  each  case,  in  inflammation, 
for  example,  according  as  it  is  very  slight  or  exceedingly  intense, 
that  this  circumstance  necessarily  influences  very  powerfully  the 
physician's  course  of  treatment.     In  one  case,  cooling  drinks  and 
diet  would  alone  be  indicated ;  in  the  other,  copious  and  frequent 
depletion  and  the  most  powerful  revulsives  should  be  employed. 

F.  The  different  periods  likewise  furnish  various  indications. 
The  treatment  of  typhoid  fever  is  unlike  in  its  first  and  third 

*  It  may  not  be  inappropriate  to  mention  in  this  connection  (although  perhaps 
more  properly  coming  under  the  head,  diminution  of  the  forces,  p.  409)  the  re- 
searches of  Dr.  Stokes  upon  the  indications  for  the  administration  of  wine  in 
fever,  which  are  derived  from  the  phenomena  of  the  heart's  action.  The  very 
valuable  and  interesting  paper  which  contains  the  account  of  these  researches  and 
the  inferences  deduced  therefrom,  may  be  found  in  the  Dublin  Medical  Journal, 
vol.  xv.  —  Dr.  Stokes  considers  that  softening  of  the  heart  exists  in  typhus 
fever,  as  a  local  disease.  The  important  conclusion  derived  from  the  asthenic 
condition  of  the  heart,  &c.  is  as  follows  :  — "  The  diminution  or  cessation  of  im- 
pulse, the  proportionate  diminution  of  both  sounds,  or  the  preponderance  of  the 
second  sound,  are  direct  and  nearly  certain  indications  for  the  use  of  wine  in  fever." 
—  TRANS. 


THERAPEUTICS.  413 

periods,  and  the  means  which  are  proper  at  the  commencement  of 
a  grave  inflammation  cannot  be  employed  to  the  same  extent  in 
the  second  or  third  week  of  its  duration.  This  rule  is  applicable 
to  nearly  all  acute  diseases,  whatever  may  be  their  genus,  course, 
or  productive  cause.  If  debilitants  be  indicated  and  evacuants 
required,  they  should  be  employed  particularly,  if  not  exclusively, 
at  the  outset  and  in  the  first  period  of  the  disease  :  they  should 
subsequently  be  resorted  to  more  cautiously,  in  proportion  as  the 
disease  advances,  without  being  entirely  proscribed.  In  the  last 
period  of  acute  and  even  chronic  diseases,  the  supervening  phe- 
nomena should  be  attentively  watched,  and  when  the  tendency  of 
nature  has  been  ascertained,  it  should  be  assisted  if  it  seem  proper; 
when  sufficiently  powerful  in  itself,  we  may  limit  our  interference 
to  the  removal  of  every  hindrance  from  its  path,  or  oppose  it  by 
the  most  energetic  means  when  necessary. 

G.  The  symptoms,  especially,  supply  us  with  indications  not 
to  be  neglected.  They  are,  it  is  true,  merely  the  effects  of  the 
disease,  and  yield,  most  frequently,  to  the  treatment  it  requires. 
But  in  certain  cases,  some  of  them  become  sufficiently  severe  to 
prove  a  serious  addition  to  the  danger  of  the  primitive  affection. 
Thus,  in  typhoid  fever,  epistaxis  may  supervene,  sufficiently  co- 
pious to  endanger  the  patient's  existence  and  demanding  the  phy- 
sician's immediate  and  constant  attention.  The  subjugation  of  the 
predominant  symptoms  is,  therefore,  justly  regarded  as  an  impor- 
tant part  of  the  treatment,  with  the  precaution,  however,  of  not 
magnifying  the  phenomena  at  the  expense  of  the  disease,  and  not 
neglecting  the  main  object  for  one  of  secondary  consequence.* 

The  indications  arising  from  the  symptoms  are  sometimes  even 
more  important,  as  in  cases  where  the  diagnosis  is  obscure :  the 
genus  of  the  disease  being  unknown,  the  symptomatic  treatment  is 
alone  admissible.  We  do  not  intend  by  this  term,  f  "  that  errone- 
ous symptomatic  treatment^  which,  without  rules  or  knowledge, 
opposes  symptoms  indifferently,  but  that  which,  enlightened  and 
firm  in  its  progress,  at  one  time  remedies  alarming  symptoms  and 
at  another  manages  the  disease  according  to  the  indications  derived 
from  a  union  of  all  the  symptoms,  which  render  it  similar  to  cer- 
tain other  affections,  until  it  be  more  accurately  defined."  Thus, 
in  many  cases,  there  will  frequently  supervene,  in  an  individual  of 
good  constitution  and  previously  in  excellent  health,  a  chill,  fol- 
lowed by  general  heat,  redness  of  the  cutaneous  surface,  full 
pulse,  etc..  and  still,  nothing,  thus  far,  may  clearly  reveal  the 
source  of  the  very  intense  febrile  action.  Although  the  diagnosis 
is  here  obscure,  the  physician  may,  and  often  should,  fulfil  the 
indications  presented  by  the  symptoms,  collectively  considered, 
prescribing  depletion,  once  or  repeatedly,  without  waiting  for  local 
signs  to  inform  him  whether  the  commencing  disease  belongs  to 

*  FRANK,  Epitome,  torn.  i. 
f  Th6se  dej&  citee  de  BAYLE. 


414 


THERAPEUTICS. 


the  thoracic   inflammations  or   to  some  other  of  the  nosological 
genera. 

H.  The  indications  derived  from  the  seat  of  diseases  demand, 
also,  particular  attention.  Generally,  the  affected  parts  should  be 
maintained  in  a  state  of  perfect  rest,  and  their  position  should  be 
such  that  the  circulation  of  the  fluids,  and  especially  that  of  the 
blood,  be  as  little  obstructed  as  possible.  The  sitting  posture  is 
peculiarly  suitable  in  diseases  of  the  head  and  chest ;  the  horizon- 
tal, in  abdominal  affections  and  those  of  the  lower  limbs ;  the 
pain  and  swelling  in  paronychia  and  rheumatic  inflammation  of  the 
hand  or  wrist  augment  when  the  hand  is  pendent,  but  diminish 
when  it  is  elevated  and  rests  upon  a  cushion;  diseases  of  the 
joints  generally  necessitate  immobility  of  the  affected  parts  ;  those 
of  the  digestive  organs  demand  a  restricted  regimen  ;  those  of  the 
chest  often  require  silence,  as  do  cerebral  affections,  mental  repose. 

I.  Certain  indications  arise  from  the  complications.  Occasion- 
ally, the  physician  disregards  one  of  the  diseases  and  devotes  his 
attention  solely  to  the  other,  but  subsequently  returns  to  the  con- 
sideration and  treatment  of  the  former;  at  another  time  (and 
this  is  most  frequently  the  case)  the  treatment  is  regulated  accord- 
ing to  the  indications  simultaneously  furnished  by  the  co-existing 
diseases  ;  for  example,  in  pneumonia  complicated  with  peritonitis, 
or  chronic  articular  rheumatism  with  syphilis,  the  indications  pre- 
sented by  each  affection  may  be  simultaneously  fulfilled. 

J.  The  productive  or  developing  causes  of  diseases,  are  highly 
important  in  regard  to  therapeutics,  and  the  physician  should 
always  endeavor  to  discover  them.  Determining  causes  supply 
us  with  very  reasonable  indications.  When  a  person  is  asphyx- 
iated by  an  atmosphere  filled  with  noxious  vapor,  the  first  indi- 
cation is  to  remove  him  from  its  influence.  When  a  foreign  body 
remains  in  a  wound,  its  immediate  extraction  is  indicated.  If 
poisonous  substances  have  been  swallowed,  it  will  be  necessary  to 
excite  emesis,  if  any  of  the  poison  remain  in  the  stomach,  or  else 
it  should  be  neutralized  by  the  administration  of  appropriate  anti- 
dotes, or  at  least,  its  action  should  be  enfeebled  by  large  draughts 
of  liquids.  If  venomous  secretions  or  virus  be  deposited  upon  any 
part,  both  the  morbific  agent,  and  the  part  which  has  received  its 
action,  should  be  destroyed  by  means  of  caustic.  In  all  these 
cases,  by  removing  the  cause,  we  may  hope  to  jugulate  the  dis- 
ease, sublata  causa,  tollitur  ejfectus.  In  imaginary  diseases,  the 
treatment  should  be  moral.  A  young  female  in  the  pauper  hos- 
pital of  Harlem,  having  had  convulsions,  many  of  the  children  at 
the  same  time  in  the  hospital,  who  had  witnessed  these  attacks, 
were  similarly  affected,  the  symptoms  being  repeated  daily,  by  a 
kind  of  imitation,  in  a  large  number.  Many  remedies  were  un- 
successfully tried.  Boerhaave,  being  consulted,  directed  that  some 
furnaces  filled  with  live  coals  should  be  placed  in  the  middle  of 


THERAPEUTICS.  415 

the  Ward  and  iron  hooks  heated  in  order  to  transfix  the  arm  of 
the  first  child  who  should  have  convulsions.  This  method  was 
completely  successful ;  no  more  convulsions  were  observed. 

General  predisposing  causes,  as  the  season,  the  state  of  the 
air,  etc.,  furnish  several  indications,  chiefly  unimportant.  It  is 
otherwise  in  regard  to  climate,  which  in  certain  catarrhal  affec- 
tions, and  some  of  the  neuroses,  has  so  great  an  influence  upon 
the  progress  of  the  disease,  that  it  becomes  the  most  efficient  agent 
in  the  treatment ;  the  substitution  of  a  warm  for  a  cold  climate 
has  frequently  been  followed  by  an  amelioration  not  to  be  obtained 
by  any  other  means. 

Temperament,  constitution,  age,  sex,  occupation,  but  especially 
the  habitual  regimen  of  patients,  are  the  sources  of  indications 
more  or  less  important.  The  sanguine  temperament,  for  example, 
indicates  depletion  in  diseases,  which,  in  themselves,  and  in  per- 
sons of  different  temperament,  would  not  require  it ;  the  necessity 
for  employing  this  means  of  treatment  is  still  more  urgent  when 
the  nature  of  the  disease  requires  it,  while  in  the  lymphatic  and 
nervous,  blood-letting  should  be  resorted  to  with  great  reserve, 
and  only  when  its  omission  would  be  seriously  injurious.  This 
rule  applies  equally  to  individuals  of  naturally  feeble  or  artificially 
debilitated  constitution.  What  has  been  said  of  sanguineous 
depletion,  naturally  applies  to  the  other  active  means  of  treatment, 
as  purgatives,  opium,  bitter  tonics  and  cutaneous  revulsives. 
When  about  to  employ  these  remedies,  the  temperament  and  con- 
stitution of  the  patients  should  be  particularly  considered. 

The  indications  derived  from  the  different  ages  are  not  unim- 
portant. The  diseases  of  children,  generally  considered,  require 
more  simple  and  fewer  remedies  than  those  of  adults.  The  dis- 
eases of  the  aged,  which  are  apt  suddenly  to  assume  an  adynamic 
character,  render  greater  reserve  in  the  administration  of  debili- 
tarits,  and  a  more  prompt  resort  to  tonics,  necessary.  Sex  also 
has  its  indications,  particularly  in  regard  to  pregnancy  and  the 
menstrual  period,  which  often  render  it  necessary  to  modify  the 
use  of  energetic  remedies,  or  to  substitute  others  of  less  power. 
The  occupation  and  place  of  residence  also  suggest  indications. 
Certain  diseases  will  continue  so  long  as  the  affected  individual 
pursues  his  occupation  or  retains  his  habitation,*  because  these 
are  their  productive  and  maintaining  causes. 

Ramazzini  observed  that  country  people,  who  labor  hard,  do 
not  bear  artificial  evacuations  so  well  as  the  inhabitants  of  cities, 
whose  life  is  more  tranquil,  and  whose  food  is  also  more  nutri- 
tive.f — When  considerable  evacuations,  excessive  fatigue,  pro- 
longed watching,  profound  grief  and  great  anxiety  of  mind,  have 
preceded  a  disease,  the  latter  is  usually  accompanied  by  a  debility 
which  necessitates  a  more  prompt  resort  than  usual  to  means  suit- 
able for  sustaining  the  strength. 

*  See  pp.  36,  43. 

f  RAMAZZINI,  des  Maladies  des  Artisans,  traduction  de  FOURCROY,  p.  451. 


416  THERAPEUTICS. 

The  physican  often  discovers  important  indications  in  the  daily 
habits  of  life.  The  various  disorders  of  the  digestive  organs,  and 
many  sympathetic  phenomena  arising  from  latent  affections  of  the 
stomach  and  intestines,  such  as  cephalalgia,  somnolency,  vertigo, 
dyspnoea  and  palpitations,  very  often  depend  either  upon  the 
number  and  proximity  of  the  meals,  (which  should  be  separated 
by  longer  and  longer  intervals  as  man  advances  in  years,)  or 
upon  their  methodical  subdivision,  or  else  upon  insufficient  exer- 
cise, or  finally,  upon  the  habit  of  commencing  study  immediately 
after  the  ingestion  of  food,  particularly  if  the  meal  have  been  a 
hearty  one.  These  symptoms,  which  resist,  for  an  indefinite 
period,  all  remedial  measures,  yield,  as  if  by  enchantment,  to 
apparently  very  slight  modifications  of  the  daily  habits,  as  the 
restriction  of  the  number  of  meals  to  two  in  adult  age,  the  estab- 
lishment of  a  longer  interval  between  the  .first  and  second ; 
refraining  from  the  use  of  meat  and  other  articles  of  slow  or  diffi- 
cult digestion  at  breakfast ;  a  change  in  the  hours  devoted  to 
exercise  or  study,  so  that  walking  exercise  be  taken  after  meals, 
and  intellectual  employments  deferred  for  one  or  more  hours. 
Nearly  all  students,  or  those  obliged  to  devote  the  entire  day  to 
intellectual  pursuits,  should  restrict  themselves  to  a  single  repast, 
resigning  almost  entirely  the  morning  meal,  so  that  the  whole  day 
may  be  devoted  to  their  occupations,  and  indulging  their  appetite 
at  dinner,  our  social  habits  having  reserved  the  evening  for  repose 
and  relaxation. 

Secondary  indications  alone  are  derived  from  most  of  the  occa- 
sional causes :  whether  the  invasion  of  pneumonia  has  been 
preceded  by  a  chill,  a  powerful  emotion,  or  errors  in  diet,  no  impor- 
tant modification  of  the  treatment  can  result  from  these  circum- 
stances. If,  however,  suppression  of  an  habitual  evacuation  have 
immediately  preceded  the  disease,  we  should  recall  or  supply  it, 
as  we  should  if  it  had  been  suspended  long  previously.  If  the 
cicatrization  of  an  ulcer,  the  dessication  of  an  issue,  or  the  sup- 
pression of  a  rheumatic  affection,  seem  to  have  excited  the  disease, 
rubefacients  or  vesicants  should  be  applied  to  the  previously 
affected  surface,  or  an  issue  should  be  established.  In  like  manner, 
chronic  affections  of  the  skin,  as  erysipelas  or  any  other  exanthema, 
should  be  re-established,  if  possible,  in  the  part  they  originally 
occupied,  by  the  application  of  a  sinapism  or  blister,  or  by  excit- 
ing an  artificial  eruption  by  means  of  croton  oil  or  antimonial  oint- 
ment. If  repercussion  of  urticaria  preceded  the  development  of 
the  disease,  the  most  rational  indication  would  be  urtication  of  the 
part  whence  the  eruption  had  disappeared.  Suppression  of  the 
sweat  most  frequently  furnishes  no  indication,  except  it  occur 
during  the  precursory  period  of  the  disease ;  the  latter  being  actu- 
ally developed,  diaphoresis  would  often  be  insufficient  to  arrest  its 
course  and  might  sometimes  increase  its  violence. 

K.  Among  the  commemorative  circumstances  there  is  one  which 
elucidates  both  therapeutics  and  diagnosis,  and  furnishes,  in  many 


THERAPEUTICS.  417 

cases,  particularly  in  chronic  affections,  indications  of  the  great- 
est importance  ;  we  refer  to  the  previous  diseases,  whose  essence, 
whatever  it  may  have  been,  might  have  influenced  the  develop- 
ment of  the  existing  malady,  without  any  revelation  of  its  nature 
being  made  by  the  apparent  form  of  that  malady.  Observation, 
indeed,  daily  shows  us  individuals,  who,  at  different  periods  after 
rheumatic  attacks,  or  one  of  those  chronic  exanthemata  commonly 
known  as  herpetic,  (yulgairement  designes  sous  la  denomination 
commune  de  dartres,)  *  are  affected  with  various  disturbances  of 
the  economy,  often  transient  and  inconstant,  sometimes  fixed  as  to 
seat,  but  very  variable  in  form  and  intensity,  and  most  frequently 
simulating  certain  chronic  phlegmasiae  or  neuroses,  either  abdomi- 
nal, thoracic  or  cerebral.  These  affections  resist  nearly  all  reme- 
dial measures,  until  the  appearance  of  an  exanthematous  eruption 
or  arthritic  or  muscular  pain  relieves  the  affected  viscera  from  their 
derangements  arid  reveals  the  productive  and  continuing  cause. 
It  would  be  impossible  to  enumerate  the  number  of  cases  where 
this  class  of  affections,  however  severe  or  chronic  they  may  have 
been,  has  yielded  to  remedies  suitable  for  subduing  or  recalling  to 
their  former  position  rheumatic  and  herpetic  diseases.  In  dis- 
guised syphilitic  affections,  we  ascertain  the  origin  of  the  existing 
malady  and  determine  its  treatment  by  a  consideration  of  the 
anterior  diseases.  In  most  chronic  diseases,  especially  those  which 
do  not  consist  in  those  profound  structural  changes  where  thera- 
peutics are  powerless,  thorough  investigation  of  every  previous 
occurrence  and  attentive  examination  of  all  the  physical,  moral, 
and  intellectual  conditions  in  which  the  patient  is  placed,  will  be 
found  to  afford  the  truest  indications  and  those  explanatory  of 
the  origin  of  the  disease  and  the  means  of  subduing  it. 

There  are  certain  other  commemorative  circumstances,  which, 
without  having  any  influence  in  the  development  of  the  disease, 
are  productive  of  particular  indications ;  among  these  are  long- 
continued  habits.  Those  who,  in  health,  are  hearty  eaters,  and 
who  drink  large  quantities  of  wine  and  spirits  daily,  cannot,  when 
ill,  support  so  severe  a  diet  as  the  more  temperate.  A  very  robust 
man,  addicted  to  the  use  of  fermented  liquors  and  accustomed  to 
take  a  pint  arid  a  half  of  wine  daily,  entered  La  Charite,  on  the 
seventh  day  after  an  attack  of  pneumonia ;  he  was  only  once 
bled,  and  from  the  succeeding  day  the  disease  declined.  A  man 
thirty-four  years  of  age  accustomed  to  eat  three  pounds  of  bread 
and  the  same  quantity  of  meat,  and  to  drink  fifteen  bottles  of 
wine  and  four  of  brandy  daily,  contracted  syphilis.  M.  Cullerier, 
when  consulted  by  him,  allowed  him  to  take  (during  the  inflamma- 
tory period)  a  pound  and  a  half  of  bread,  the  same  amount  of 
meat,  three  bottles  of  wine  and  one  of  brandy.f  Being  convinced 
of  the  injurious  effects  of  a  sudden  interruption  of  even  the  worst 

*  The  term  dartre  has  been  applied  to   nearly  every  disease  of  the  skin. 
(Dunglison.)  —  TRANS. 
f  Theses  de  TEcole  de  Paris,  ann.  1809,  No.  17. 


418  THERAPEUTICS. 

habits,  we  published,  nearly  twenty-five  years  ago,  in  the  New 
Journal  of  Medicine,*  a  paper  upon  the  use  of  wine  in  the  acute 
diseases  of  the  intemperate.  Since  then,  we  have  allowed  these 
individuals,  under  such  circumstances,  a  certain  quantity  of  wine, 
either  pure  or  mingled  with  other  fluids  (tisanes),  and  have  never 
had  occasion  to  regret  it,  having  always  observed  death  to  occur 
in  those  who  had  been  entirely  deprived  of  wine  during  the 
disease. 

There  is  still  another  commemorative  circumstance  that  occa- 
sionally furnishes  useful  indications ;  if  the  patient  have  once,  or 
several  times,  previously,  had  illness  similar  to  that  under  treat- 
ment, we  should  inquire  what  means  were  then  employed ;  if  the 
same  were  resorted  to  in  every  attack  and  what  their  effect  has 
been.  If  the  same  remedy  has  been  always  successfully  em- 
ployed, it  should  be  repeated,  except  in  certain  cases  where  the 
physician's  judgment  forbids ;  if  many  different  remedies  have 
been  tried,  that  most  constantly  productive  of  relief  should  be 
selected;  if,  on  the  contrary,  any  means  which  had  seemed  to  be 
indicated  by  the  kind  of  disease  or  any  other  circumstance  have 
proved  injurious,  they  should  be  abandoned. 

Before  prescribing  any  medicine,  the  physician  should  ascertain 
if  the  patient  have  taken  it  for  any  other  affection,  and  also  the 
effects  produced,  and  whether  he  is  favorably  or  unfavorably  im- 
pressed by  it.  There  are  persons  in  whom  opiates  always  act  unfa- 
vorably; this  idiosyncrasy  {particularity}  should  be  known  in  order 
that  we  may  refrain  from  prescribing  them.  There  are  others  who 
have  a  decided  aversion  to  these  medicines  or  a  great  dread  of  their 
effects ;  if  necessary  to  resort  to  them,  they  should  be  disguised. 

L.  When  a  disease  has  continued  several  days,  and  various 
remedial  means  have  already  been  tried,  their  influence  upon  the 
intensity  of  the  symptoms  may  supply  important  indications  which 
are  of  still  more  consequence  where  the  genus  of  the  disease  is 
unknown,  or  in  cases  when  the  disease  being  understood,  the  treat- 
ment is  doubtful.  Tn  many  chronic  diseases  the  physician  relies 
principally  upon  such  indications,  acting,  as  the  saying  is,  a  ju- 
vantibus  et  Icedentibus.  In  certain  acute  diseases,  where  the  appre- 
ciation of  the  vital  forces  is  difficult,  the  effect  of  the  remedies  first 
administered  is  exceedingly  important  in  enabling  us  to  ascertain 
their  true  condition  and  in  supplying  us  with  indications.  The 
efficacy  or  insufficiency  of  sulphur  or  mercury  in  certain  diseases, 
furnishes,  after  a  certain  time,  new  indications  in  regard  to  their 
continuance  or  suspension,  etc.  It  should  not,  however,  be  forgot- 
ten, that  the  majority  of  acute  diseases,  particularly  the  phleg- 
masise,  exhibit  a  continued  aggravation  (period  of  increase)  for 
several  days,  notwithstanding  the  use  of  the  most  powerful  medi- 
cines, and  that,  in  this  case,  the  exasperation  of  the  symptoms,  while 

*  Nouveau  Journal  de  M6decine,  torn.  vii.  p.  181. 


THERAPEUTICS.  419 

restricted  within  certain  limits,  by  no  means  proves  that  the  reme- 
dies administered  were  not  indicated. 

M.  When  a  disease  prevails  epidemically,  certain  indications 
arise  from  other  circumstances :  as  1st,  an  exact  comparison  of 
the  causes  and  form  of  the  existing  epidemic  with  those  observed 
in  the  preceding,  may  furnish  indications  for  treating  those  first 
attacked  ;  2dly,  when  a  certain  number  of  cases  has  been  observed, 
and  the  effect  of  remedies  has  been  attentively  watched,  conclusions 
may  be  formed  in  regard  to  subsequent  treatment.  When,  how- 
ever, the  epidemic  persists,  the  indications  may  vary  during  its 
continuance,  and  the  treatment  originally  successful  may  be  in- 
sufficient or  injurious  toward  the  termination.* 

N.  The  tendency  of  a  disease  to  different  terminations  requires 
also  the  physician's  attention.  If  the  termination  is  likely  to  be 
favorable,  his  care  may  be  employed  in  the  simple  removal  of  all 
aggravating  circumstances,  or  in  fulfilling  the  secondary  indica- 
tions already  existing  or  subsequently  supervening,  and  all  active 
medication  may  be  abandoned,  except  the  disease  continue  a  long 
time  and  there  be  no  therapeutical  means  capable  of  suspending  or 
abridging  its  duration. — If  there  be  a  tendency  to  a  fatal  termina- 
tion, the  most  energetic  means  for  its  prevention  should  be  tried  ; 
but  when  death  is  inevitable,  the  indications  are  restricted  to  treat- 
ing the  principal  symptoms,  with  the  intention  of  prolonging  life 
or  rendering  its  last  moments  less  painful.  —  If  the  disease  neither 
increase  nor  diminish,  as  in  paralysis,  the  perturbating  treatment 
is  generally  resorted  to ;  this  consists  in  the  employment  of  reme- 
dies likely  to  produce  a  powerful  diversive  effect :  this  treatment, 
however,  would  be  dangerous,  if  the  disease,  which  is  really  sta- 
tionary, were  of  a  nature  liable  to  be  exasperated  by  its  employ- 
ment :  in  certain  cases  of  mammary  cancer,  for  example,  great 
care  should  be  taken  not  to  employ  active  remedies  when  the 
disease  is  stationary,  because  all  change  must  necessarily  be  inju- 
rious, p—  In  certain  acute  diseases  which  may  terminate  in  death  or 
the  return  to  health,  active  treatment  should  be  employed  if  the  in- 
dications be  decided ;  the  opposite,  if  they  be  obscure  :  perturbating 
treatment  would  not  be  proper,  for  example,  in  all  the  forms  of 
adynamic  typhoid  fever.  These  affections,  notwithstanding  the 
apparent  disorder  frequently  accompanying  them,  are  not,  more 
than  other  diseases,  a  state  of  confusion,  but  rather  a  sort  of 
struggle  between  vitality  and  the  causes  which  have  disturbed  its 
harmonious  action,  —  a  struggle  whose  issue  is  doubtful.  In  this 
state  of  uncertainty,  should  we  indiscriminately  and  in  every  case 
endeavor  to  disturb  the  course  of  these  diseases,  or  merely  confine 
ourselves  to  meeting  the  precise  indications  that  maybe  presented? 
We  unhesitatingly  advocate  the  latter  course. 

*  fUMAZzmi,  Epidem.  mutin.,  arm.  1691,  in  SYDEINHAMI  Oper.  torn  ii.  p.  38. 
Genevee,  1736. 


420  THERAPEUTICS. 

O.  The  influence  which  may  be  exerted  by  the  disease  upon 
the  patient's  constitution  and  upon  previous  affections  is  also  of 
service  to  the  physician.  If  the  disease  disturb  the  functions  of 
the  organs  remote  from  its  apparent  seat,  and  particularly  of  the 
locomotive  and  digestive  apparatus,  or  if  it  aggravate  pre-existing 
affections,  its  coarse  should  be  arrested  as  speedily  as  possible.  If, 
on  the  contrary,  the  appetite  and  digestion  improve  after  the 
appearance  of  a  cutaneous  eruption  or  an  attack  of  intermittent 
fever;  if  the  individual  perceive  an  increase  of  strength,  if  certain 
uncomfortable  sensations,  long  experienced,  cease  completely,  etc., 
the  progress  of  the  disease  should  not  be  interrupted,  all  opposing 
influences  should  be  removed,  and  if  anything  suddenly  arrest  it, 
it  should,  if  possible,  be  reproduced.  In  proportion  as  its  course  is 
favorable,  the  remedy  will  be  unfavorable,  morbi  boni,  remedia 
mala.*  There  are,  then,  diseases  which  it  is  dangerous  to  cure, 
as  is  proved  by  the  collection  of  observations  published  upon  this 
important  point  in  therapeutics:!  their  number,  .however,  is  not 
very  large,  and  the  dissertation  of  Werlhoff,  De  limitanda  febris 
laude,  need  not  now  be  read  in  order  to  establish  the  truth  of  the 
assertion.  We  must  refer  to  the  period  when  this  work  was  writ- 
ten, to  avoid  being  astonished  that  any  one  should  have  seriously 
endeavored  to  establish  such  a  proposition. 

Such  are  the  principal  circumstances  from  which  indications  for 
treatment  are  derived.  They  are  not  all  equally  important ;  but 
none  of  them  can  be  neglected  without  detriment.  It  is  evident 
from  the  above  considerations,  how  erroneous  is  the  opinion  of 
those  who  believe  that  there  is  a  remedy  for  every  disease,  and 
how  different,  a  treatment  founded  upon  experience,  from  empir- 
icism ;  the  modifications  of  treatment  are  also  manifest  that  are 
founded  upon  the  numerous  indications  which  combine  and  form, 
as  it  were,  out  of  every  disease,  an  affection  dissimilar,  in  some 
.respects,  both  as  to  treatment  and  symptoms,  from  all  those  that 
most  resemble  it.  It  is  not,  as  has  been  judiciously  remarked, 
dropsy  or  peripneumonia,  simply,  that  is  treated,  but  those  diseases 
as  manifested  in  various  individuals,  of  different  ages,  sex,  tempera- 
ment, habits,  etc.J  The  great  number  of  circumstances,  which 
should  all  be  considered  and  their  value  appreciated  in  order  to 
perceive  the  indications,  causes  the  difficulty  experienced  in  the 
detection  of  the  latter. 

There  are  but  few  cases  in  which  a  single  indication  only  is 
manifest;  in  nearly  all  diseases  there  are  many.  These  simulta- 
neous indications  maybe  analogous  and  concur  in  the  same  object, 
as  general  bleeding,  abstinence  and  topical  emollients,  all  of  which 
should  be  combined  in  certain  inflammations.  But  this  is  not 
always  the  case,  and  sometimes,  while  certain  circumstances  indi- 

*  WERLHOFF,  Dissert,  de  limitanda  febris  laude.     Opera,  torn.  ii. 

f  Traite  des  Maladies  quil  est  dangereux  de  guerir,  par  Dom.  Raymond. 

j  Nee  pneumoniam  generatim,  nee  hydropem  curamus,  sed  pneumoniam  Sem- 
pronii  aut  Tulliae,  sexu,  atate,  victus  genere,  aut  temperamento  differentium. — 
JSpRENGEL,  Pathol.  general,  p.  72. 


THERAPEUTICS.  421 

cate  one  sort  of  treatment,  others  oppose  its  application.  These 
opposite  indications  are  called  counter  indications.  In  typhoid 
pneumonia  there  exists,  on  the  one  hand,  an  inflammation  requiring 
debilitating  treatment,  and  on  the  other,  a  depression  of  the  vital 
powers  demanding  entirely  different  remedies.  It  cannot  be  dis- 
guised that  these  cases  are  very  embarrassing  :  if  the  inflammation 
be  combatted,  the  debility  is  increased  ;  if  tonics  be  employed,  the 
inflammatory  symptoms  are  likely  to  become  exasperated.  In  such 
an  emergency  matured  tact  is  requisite  for  the  accurate  apprecia- 
tion of  the  relative  value  of  the  opposing  indications,  meeting  the 
most  urgent  as  completely  as  possible,  taking  care  that  the  means 
employed  be  favorable  to  one  of  the  morbid  conditions  without 
aggravating  the  other,  or  that  the  evils  arising  from  the  use  of 
certain  remedies  may  be  more  than  counterbalanced  by  their  bene- 
ficial action. 

Embarrassment  in  regard  to  the  treatment  of  a  disease  may 
occur  from  other  causes  than  the  existence  of  counter  indications. 
It  sometimes  happens  that  an  acute  or  chronic  disease  exhibits 
more  or  less  serious  symptoms  without  furnishing  any  decided 
indication.  Should  active  means  be  tried  in  these  cases,  and  a 
species  of  instinct  be  obeyed  which  would  lead  us  to  suspect  certain 
indications  of  which  we  are  doubtful  ?  Some  practitioners  pursue 
such  a  course,  but  we  should  be  unwilling  either  to  adopt  or  advise 
it:  we  act  blindly  when  destitute  of  positive  indications.  The 
judicious  reserve  of  Sydenham  and  Morgagni  may  be  fearlessly 
imitated  in  such  circumstances,  while  an  opposite  course  would 
often  be  regretted.  "  I  need  not  blush  to  confess,"  says  the  former. 
"  that  in  the  management  of  fevers.  I  have  many  times  congratulat- 
ed myself  upon  refraining  from  action  when  nothing  manifestly  fur- 
nished indications  of  treatment :  while  thus  attentively  watching 
the  course  of  the  disease,  in  order  to  seize  the  favorable  moment 
for  attack,  the  fever  either  vanished  spontaneously,  or  assumed  a 
form  which  indicated  the  remedies  to  be  employed."*  "In  cer- 
tain chronic  diseases  of  doubtful  nature,"  says  Morgagni,  "  we 
should  not  proceed  rashly,  but  restrict  ourselves  to  the  employment 
of  remedies  sanctioned  by  experience,  which,  while  incapable  of 
inflicting  injury,  generally  relieve  to  a  certain  extent."!  Utility 
is  only  the  second  rule  of  therapeutics ;  the  first  is  avoidance  of 
injury. 

We  do  not,  however,  mean  to  imply,  that  in  acute  or  chronic 
diseases,  the  physician  should  constantly  abstain  from  all  active 
treatment,  because  the  indications  are  obscure ;  but  the  greatest 
circumspection  is  requisite  in  its  employment.  For  this  reason 

*  Neque  pudetfateri,  me  non  semel  in  curandis  febribus,  ubi  nondiim  constant 
quid  mihi  agendum  esset,  nihil  prorsus  agenda  et  mihi  et  cegro  consulvisse  uptime; 
dum  enim  morbo  incigilarem,  quo  eum  upportumus  confudere  voter  em,  febris  vet 
sponte  sud  sensim  evanuit,  vel  ^n  eum  se  typum  redegit,  ut  jam  mihi  innotescerct 
quibus  armis  esset  dcbellenda  —  (SYDENHAM,  torn.  viii.  p.  158.) 

f  Temerl  nihil  audendum,  sed  its  qua  levaminis  aliquid  qfferre  hactenw  con- 
suescunt,  innoxiis  remediis  utendum. — De  Sedibus  et  Causis  Morbor.  Ixiv.  5. 

36 


422  THERAPEUTICS. 

cinchona  is  cautiously  tried  in  certain  affections  resembling  inter- 
mittent fever,  and  mercury  employed  in  those  suspected  to  be  of 
syphilitic  origin.  These  remedies  become  in  such  cases  a  sort  of 
touchstone. 

There  have  existed  physicians  in  all  ages,  who  have  been  distin- 
guished either  by  a  dangerous  predilection  or  an  antipathy  nearly 
as  blameable  for  certain  indications.  Some  have  seen,  in  every 
disease,  indications  for  depletion  and  emesis  ;  others  always  purged 
their  patients  without  exception,  either  during  the  course  of  the 
disease  or  subsequently  ;  or  else  administered  tonics  indiscrimi- 
nately. Others,  adopting  the  opposite  extreme,  asserted  that  such 
indications  never  existed,  and  that  blood-letting,  cinchona  and 
purgatives  were  always  injurious.  We  shall  not  attempt  to  prove 
how  erroneous  and  dangerous  are  these  opinions  ;  their  mention 
alone  is  sufficient  for  their  reciprocal  destruction.  There  is  no 
remedy  of  unfailing  utility,  nor  any  which  is  constantly  injurious  ; 
this  is  so  evident  that  we  should  not  have  noticed  it,  had  not  these 
exclusive,  we  might  say  absurd,  opinions  received  the  sanction  of 
celebrated  names. 

The  aim  of  medical  treatment  is  not  merely  to  combat  the  exist- 
ing disease  ;  it  should  be  also  directed,  either  to  the  prevention  of 
those  maladies  that  threaten  the  healthy,  or  to  hastening  the 
re-establishment  of  the  functions  in  the  convalescent  :  there  are 
prophylactic*  or  preservative  indications,  and  also  those  of  conva- 
lescence and  the  consecutive  phenomena  of  diseases. 

Preservative  indications  occur  in  various  circumstances.  1.  The 
offspring  of  parents  affected  by  hereditary  disease,  should  be  sub- 
jected to  treatment  suitable  for  modifying  this  unfortunate  predis- 
position to  its  transmission.  2.  When  the  precursory  signs  of  a 
given  disease  are  observed  in  any  person,  they  furnish  a  prophy- 
lactic indication  which  it  is  sometimes  very  necessary  to  fulfil,  as, 
for  example,  in  threatened  apoplexy.  3.  An  individual  who  has 
been  once,  or  more  frequently  affected  with  a  disease  of  frequent 
recurrence,  as  rheumatism,  gout,  etc.,  should  take  the  appropriate 
measures  to  prevent  its  return.  4.  If  a  disease  prevail  epidemi- 
cally, various  prophylactic  indications  arise,  from  its  form,  causes, 
etc.  :  they  are  founded,  in  all  these  cases,  upon  ordinary  therapeu- 
tical bases.  5.  When  contagious  disease  appears  in  any  place, 
there  is  a  peculiar  indication  for  the  preservation  of  those  who 
cannot  escape  the  danger  of  its  contraction  by  flight  ;  this  is,  for- 
bidding all  communication,  direct  or  indirect,  with  the  patients. 
In  this  way  the  Orphan  Asylum  of  Moscow  was  preserved  f  from 
the  plague  which  desolated  that  city,  and  the  Hottentots  thus  shel- 
tered themselves  from  variola  brought  to  the  Cape  of  Good  Hope 
by  a  European  vessel  ;  thus,  also,  during  many  pestilential  dis- 
eases, certain  cities,  or  particular  quarters  of  them,  or  a  number  of 
houses,  have  been  kept  from  the  contagion.  The  same  may  be 


w,  I  anticipate  :  from  (pvluaaw,  I  guard  ;  and  TIQO,  in  advance. 
MERTENS,  torn.  i.  p.  203.  —  MEAD,  Opera,  p.  306. 


THERAPEUTICS.  423 

said,  in  like  cases,  of  the  peculiar  individual  indications  for  those 
who,  from  their  profession  or  duties,  are  obliged  to  visit  or  remain 
with  the  sick.  6.  When  a  disease  prevails  or  reappears  endemi- 
cally  in  any  place,  it  gives  rise  to  indications  of  another  kind.  If 
neighboring  marshy  grounds  occasion  intermittent  fever  every 
autumn,  it  will  be  necessary  to  drain  the  marsh,  or  to  surround  it 
with  a  perpendicular  enclosure,  or,  what  is  preferable,  to  convert 
the  stagnant  water  into  a  continual  stream.  The  fetid  and  corrupted 
water  of  a  river  caused  devastating  disease  throughout  an  entire 
province ;  Empedocles  increased  the  rapidity  of  its  current  by  con- 
necting with  it  two  other  rivers;  the  diseases  never  reappeared. 

In  convalescence,  the  principal  indications  are  gradually  to  re- 
establish the  strength  by  suitable  regimen,  considering  the  patient's 
general  debility,  and  that  of  the  digestive  organs  particularly  :  by 
regimen  we  mean,  not  only  the  choice  and  quantity  of  food,  but 
also  everything  connected  with  those  general  attentions  by  which 
the  convalescent  should  be  surrounded.  —  When  there  is  a  ten- 
dency to  reproduction  of  the  disease,  as  is  the  case  in  intermittent 
fevers,  it  is  often  necessary  and  always  useful  to  prolong  the  use 
of  a  successful  medication  during  a  portion  of  convalescence. 

For  a  long  period,  purgation  of  all  convalescents  was  considered 
a  therapeutical  axiom.  This  practice,  which  was  not  unattended 
with  danger,  has  now  become  obsolete;  but,  as  too  frequently 
happens,  the  opposite  extreme  was  adopted,  and  the  absolute  pro- 
scription of  purgatives  in  convalescence  is  not  without  its  objec- 
tions. The  prudent  physician  will  adopt  neither  of  these  exclusive 
rules ;  he  fulfils  an  evident  indication  for  purging  when  it  exists 
in  convalescence,  but  declines  such  procedure  in  opposite  circum- 
stances. * 

The  indications  derived  from  consecutive  phenomena  vary  ac- 
cording to  the  previous  diseases  and  the  phenomena  themselves. 
In  such  cases,  the  physician  must  not  lose  sight  of  the  state  of  de- 
bility in  which  the  previous  disease  has  left  the  convalescent,  nor 
of  the  danger  of  relapse.  Both  these  considerations  should  be 
weighed,  when  the  most  appropriate  treatment  for  the  consecutive 
phenomena  is  desired. 

Having  enumerated  the  principal  sources  from  which  indica- 
tions arise,  we  shall  glance  at  the  means  employed  for  their  fulfil- 
ment. 

ARTICLE    SECOND. 
Therapeutical  Means. 

THE  general  term,  therapeutical  means,  comprises  all  that  may 
be  employed  by  the  physician  for  the  restoration  of  health.  Air, 

*  "  Nee  reconvale$cc,ns  omnis  aut  tiim  sollicitb,  aut  film  pared  nutriendus,  aut 
alvo  purgandus,  aut  demwn  roborandus.  sed  sua  cuivis  morbo,  subjecto,  afati,  etc., 
recnnvalescentia  est,  qua.  dicetam  sibi  propriam  et  medico  menta  interna,  externa,  aut 
varia,  aut  nulla  sibiexposcit."  —  FRANK,  Epitome,  i.  35. 


424  THERAPEUTICS. 

habitation,   regimen,  abstinence,  exercise,  amusements,  etc.,  are 
therapeutical  means  equally  with  remedies,  properly  so  called. 

From  the  above  enumeration  we  readily  perceive  that  they 
are  almost  infinite.  All  natural  bodies,  every  artificial  combi- 
nation, every  vital  act,  even,  become  appropriate  means  for  the 
fulfilment  of  indications.  We  shall  not  consider  them  in  detail, 
but  only  in  a  general  manner.  With  this  intention  we  shall  divide 
them  into  two  classes :  in  the  first,  we  shall  place  therapeutical 
means  properly  so  called ;  in  the  second,  general  or  hygienic 
means. 


SECTION  FIRST. 
Therapeutical  Means,  properly  so  called. 

Therapeutical  means  proper,  differ  from  hygienic  means,  by 
reason  of  the  latter  being  equally  applicable  to  the  healthy  and  the 
diseased  individual,  and  tending  alike  to  preserve  health  and  op- 
pose disease,  while  the  former  are  particularly  directed  to  the 
treatment  of  the  disease,  and  are  applicable  only  to  those  affected 
or  threatened  by  it.  They  have  been  divided  into  external  or 
surgical,  and  into  internal  or  medicinal. 

$  I.  Surgical  or  external  means  have  been  described  in 
various  series :  in  the  first,  are  enumerated  those  which  act  syn- 
thetically, *  that  is,  by  the  union  of  divided  parts,  or  the  restor- 
ation of  those  which  are  displaced:  such  are  uniting  bandages 
and  agglutinative  plaster  for  wounds,  splints  for  fracture,  taxis  in 
hernia,  etc.  in  the  second  series  (diceresis).^  are  included  all 
those  operations  that  consist  in  the  division  of  entire  parts  by 
means  of  the  hand,  the  knife  or  caustics  :  all  incisions,  from 
simple  phlebotomy  to  gastrotomy,  appertain  to  diaeresis.  In  the 
third  series  (exceresis)  {  are  united  all  the  methods  employed  for  the 
extraction  of  foreign  bodies  or  injurious  substances :  the  extraction 
of  urinary  calculi,  and  the  destruction  of  poisoned  or  envenomed 
parts  by  caustics,  belong  to  this  series.  The  fourth  series  (pro- 
thesis)  $  includes  all  the  mechanical  appliances  intended  to  sup- 
ply the  place  of  missing  or  deformed  parts.  This  division  of  the 
surgical,  is  no  more  exempt  from  imperfections  than  that  of  the 
medical,  means.  The  same  operation  sometimes  necessitates  the 
concurrence  of  means  from  each  of  these  four  series,  and  the  most 
simple  operations  frequently  require  the  aid  of  several :  ||  in  the 
operation  for  strangulated  hernia,  for  example,  there  is  division, 

*  0tu>,  T/dijut,  I  place;  auv,  with. 
t    JiuiQita,  I  divide. 
t  '-ES,  from  ;  al'Qw,  I  draw, 
ft   Otw,  Tlfypi,  1  substitute  ;  TTQO,  instead  of. 

|  Traitt  des  Maladies  chirurgicales  et  des  Operations  qui  leur  conviennent,  par 
BOYER.  Paris,  1814-1816. 


THERAPEUTICS.  425 

reduction,  application  of  a  bandage  in  order  to  remedy  the  weak- 
ness of  the  abdominal  parietes.  and  occasionally  removal  of  a  por- 
tion of  gangrenous  epiploon  or  intestine. 

§  II.  The  means  belonging  to  internal  pathology  are  yet  more 
insusceptible  of  methodical  classification.  None  of  the  divisions 
hitherto  proposed  has  met  with  universal  acceptance.  The  old 
division  of  remedies  into  evacuants  and  alterants  is  entirely  aban- 
doned at  the  present  day,  and  those  which  have  been  substituted 
are  hardly  more  satisfactory. 

Remedies  should  be  classed  wholly  by  their  action  upon  the 
economy :  this  action  being  nearly  always  complex,  often  variable, 
and  sometimes,  in  entire  opposition  to  the  intended  effect,  in  certain 
individuals  and  diseases,  the  difficulty  of  making  a  regular  division 
is  apparent:  on  this  account,  we  are  obliged  to  class  remedies  rather 
according  to  the  intention  with  which  they  are  employed  than  by 
their  effects.  The  principal  intentions  in  the  administration  of  rem- 
edies are  to  increase  or  diminish  the  evacuations,  to  augment  or 
reduce  the  strength,  to  calm  or  stimulate,  and  to  oppose  diseases  by 
those  specifics  whose  action  tends  to  arrest  their  progress :  we  may 
thus  divide  nearly  all  remedies  into  seven  principal  classes,  viz., 
evacuants  and  astringents,  debilitants  and  tonics,  sedatives  and  stim- 
ulants, and,  lastly,  specifics.  We  are  the  first  to  perceive  the  defects 
of  this  classification,  but  we  think  they  exist  in  all  others,  which 
have  the  additional  inconvenience  of  far  greater  complication. 
The  evacuants,  it  is  true,  do  not  always  produce  evacuations,  and 
astringents  sometimes  increase  them;  substances  of  reputed  debili- 
tating influence  may  occasionally  augment  the  strength  ;  we  are 
aware  that  sedatives,  and  particularly  opium,  have  sometimes 
caused  actual  stimulation,  and  that  properly  speaking,  there  are 
no  specifics ;  but  if,  as  has  been  very  judiciously  observed,  the 
positive  is  found  only  in  the  human  imagination,  and  exists  no- 
where in  the  acts  of  nature,  we  cannot  require  its  presence  in  the 
object  now  under  consideration,  *  and  even  numerous  exceptions 
should  not  prevent  us  from  considering,  in  a  general  manner,  the 
potassio-tartrate  of  antimony  as  emetic,  blood-letting  as  debilitating, 
opium  as  sedative,  ammonia  as  stimulating,  cinchona  and  mercury 
as  specifics  f  in  the  treatment  of  intermittent  fever  and  venereal 
diseases. 

*  The  majority  of  remedies  display  a  complex  action,  and  may,  for  this  reason, 
be  divided  into  several  classes.  Purgatives  are  debilitating  and  evacuant ; 
cinchona  is  tonic  and  febrifuge  ;  some  of  the  diuretics  are  stimulant  and  even  tonic, 
etc.  This  inconvenience  is  inherent  in  the  subject,  and  is  found  in  all  classifi- 
cations. 

f  The  number  of  specific  remedies  is  very  small  ;  mercury,  cinchona  and  sul- 
phur are  the  only  ones  deserving  this  appellation  ;  vaccinia  may  be  added,  whose 
effect  is  only  preservative.  There  can  be  no  specific  remedies,  except  for  diseases 
arising  exclusively  from  specific  causes  :  syphilis,  scabies,  variola  and  intermittent 
fever  are,  thus  far,  the  only  affections  for  which  specific  remedies  are  known  :  it 
may  be  considered  certain,  that  if  new  specifics  are  hereafter  discovered,  they  will 
be  applicable  to  affections  produced  by  specific  causes,  such  as  rabies,  scarlatina 

36* 


426  THERAPEUTICS. 

We  have  previously  shown,  (while  explaining  the  rules  which 
should  guide  the  physician  in  experimentation,)  how  delicate  and 
difficult  is  the  appreciation  of  therapeutical  means;  we  insisted 
upon  the  necessity  of  not  prescribing,  in  the  majority  of  cases,  but 
one  remedy  at  a  time.  Medication  was  entirely  different  in  the 
times  preceding  our  own.  Physicians  thought  it  indispensable  to 
encumber  their  prescriptions  with  a  crowd  of  ingredients,  even 
when  the  disease  required  no  medicine ;  a  draught  which  did  not 
contain  at  least  five  ingredients  would  have  been  faulty  in  its 
composition,  and  the  prescriber  would  have  been  accused  of  ig- 
norance, or  at  least  of  carelessness.  Time  has  shown  the  absurdity 
of  such  medication,  and  poly  pharmacy  *  has  but  a  few  interested 
or  credulous  proselytes,  whose  number  diminishes  daily.  Medical 
men  are  not  alone  in  condemning  this  practice ;  the  public  perceive 
how  useless  and  ridiculous  are  these  monstrous  combinations  of  all 
kinds  of  drugs,  which  often  endanger  the  patient's  life,  and  essen- 
tially impede  the  progress  of  our  art. 

This  great  reform  in  practical  medicine,  to  which  the  genius  of 
Pinel  so  powerfully  contributed,  has  already  been  productive  of 
excellent  results,  and  promises  infinite  advantages  to  the  profession. 
In  most  cases,  it  is  by  the  employment  of  only  a  single  remedy  at 

and  rubeola.  Epilepsy,  on  the  contrary,  which  depends  upon  various  causes,  can 
never  have  a  specific  remedy.  —  [Why  may  not  iodine  be  considered  a  specific  in 
the  treatment  of  bronchocele  ?  Although  not  holding  the  same  rank  with  mercury 
and  cinchona  in  regard  to  specific  action,  there  seems  sufficient  evidence  of  its 
efficacy  in'this  disease  to  give  it  a  claim  to  the  above  title.  —  Pereira  distinctly 
applies  the  term  ;  mentioning  the  uses  of  iodine,  and  comparing  its  therapeutical 
influence  with  that  of  mercury,  he  says,  "Iodine  evinces  a  specific  influence  over 
the  diseases  of  certain  organs  (e  g.  the  thyroid  body,)  which  mercury  does  not." 
And  he  subsequently  adds,  "Of  all  the  remedies  yet  proposed  for  bronchocele, 
this  has  been  by  far  the  most  successful.  Indeed,  judging  only  from  the  numerous 
cases  cured  by  it,  and  which  have  been  published,  we  should  almost  infer  that  it 
was  a  sovereign  remedy."  —  (Mat.  Med.  and  Therap.  vol.  i.  p.  2<!8,  Amer.  edit.) 
Dr.  Copland,  (Med.  Diet.  —  cited  by  Pereira,)  remarks  that  of  several  cases 
treated  by  him,  "  there  has  not  been  one  which  has  not  either  been  cured  or 
remarkably  relieved  by  it."  Bayle  (Bibliotheque  de  Therapeutique,  torn.  i.  p. 
394,)  gives  a  summary  from  several  authors ;  out  of  364  cases  treated  by  iodine, 
274  were  cured.  —  Trousseau  and  Pidoux,  after  noticing  the  extraordinary  suc- 
cess obtained  by  Coindet  in  bronchocele,  by  the  use  of  iodine,  (cure  in  two  thirds 
of  the  cases)  proceed  to  explain  the  probable  reasons  why  the  remedy  often 
fail?  ;  they  consider  it  to  be  chiefly  owing  to  the  modifications  in  the  form  of  the 
disease.  The  simple  goitre,  which  is  only  an  hypertrophy  of  the  thyroid  gland, 
disappears  readily  under  the  influence  of  iodine,  which  will  naturally  have  less 
effect  where  there  is  degeneration  of  the  tissue  of  the  glands,  such  as  the  scirrhous, 
encephaloid,  tuberculous,  osseous,  tophaceous,  cartilaginous  and  encysted  for- 
mations, sometimes  noticed.  These  considerations  are  also  suggested  by  Pereira, 
( Op.  cit.  p.  229,)  Trousseau  and  Pidoux  mention  the  curious  fact  of  the  cure  of 
goitre  being  accomplished  by  the  simple  removal  from  the  region  where  it  was 
contracted  to  countries  where  it  is  not  endemic  (L'Eveille,  Eymery,  Fodere, 
J/ard),  without  any  remedy  being  administered.  (Traiti  de  Therapeutique  et  de 
Matiere  Medtcale,  torn.  i.  p.  267.)  — The  failure  of  iodine  in  cases  complicated  by 
the  above  degeneration  of  the  glandular  texture  is  no  more  surprising  than  that  of 
mercury  under  like  circumstances  in  its  own  peculiar  province.  We  cannot  see 
why  the  title  specific  may  not  be  appropriately  applied  to  iodine.]  —  TRANS. 
*  Pulypharmacy  ;  nolvg,  many;  (paquaxuv,  a  remedy. 


THERAPEUTICS.  427 

once  that  we  can  properly  appreciate  its  effects  upon  the  system, 
and  consequently  dispel  some  of  the  darkness  which  still  surrounds 
the  most  important  branch  of  medicine.  While  we  condemn  the 
simultaneous  employment  of  a  large  number  of  remedies,  we  mean 
those  only  of  an  active  character,  for  others  may  be  combined 
without  risk  of  injury,  in  accordance  with  the  taste  and  even  the 
caprices  of  the  patient :  the  simultaneous  or  alternate  adminis- 
tration of  an  infusion  of  violet  flowers  or  of  mallows,  of  anchusa 
officmalis,  or  of  mullein  leaves,  is  to  employ  several  remedies,  but 
the  treatment  is  not  thereby  changed,  the  action  of  all  these  means 
being  not  sensibly  different.*  There  are  cases  also  where  it  is 
necessary  to  combine  several  active  remedies,  as  depletion  and 
emetics,  cinchona,  wine  and  blisters ;  but  when  the  severity  and 
pertinacity  of  the  disease  do  not  require  it,  one  remedy  at  a  time  is 
preferable. 

The  indications  not  being  the  same  throughout  the  whole  course 
of  a  disease,  it  is  generally  necessary  to  change  the  medication. 
Tonics  may  be  indicated  in  the  latter  period  while  depletion  was 
required  at  the  commencement;  but  these  alterations  should  be 
gradual,  and  it  hardly  ever  happens  that  opposite  remedies  are 
indicated  upon  alternate  days.  Thus,  in  grave  fever  supervening 
in  a  young  man,  the  inflammatory  symptoms  manifested  at  its 
commencement  require  debilitants,  particularly  blood-letting; 
later  in  the  disease,  weakness  no  longer  admits  of  bleeding ;  still 
later,  the  employment  of  some  slight  tonic  is  indicated,  which  is 
administered  in  small  doses,  and  only  during  the  remission ;  the 
dose  may  be  increased  daily  and  given  at  shorter  internals ;  finally, 
when  the  adynamic  symptoms  are  fully  established,  and  particular- 
ly, when  there  is  diminution  of  heat  and  slow  pulse,  the  most  ener- 
getic tonic  remedies  should  be  employed,  as  extract  of  cinchona, 
camphor,  generous  wines,  etc.  In  this  case,  the  means  employed 
at  the  commencement  and  at  the  termination  of  the  same  disease 
are  in  complete  opposition;  but  the  treatment  cannot  be  ques- 
tioned, because  there  is  the  same  change  in  the  phenomena  of  the 
disease.  Far  different  would  be  the  case,  if  the  physician,  con- 
stantly fluctuating  in  his  opinion  upon  the  nature  of  the  affection, 
and  imagining  opposite  indications  every  little  while,  in  the  same 
disease,  should  each  day  lay  aside  the  prescriptions  of  the  previous 
evening,  and  resume  those  he  had  once  before  abandoned.  How- 
ever various  may  be  the  forms  of  disease,  no  excuse  can  be  thence 
derived  for  such  vacillation,  which  always  indicates,  in  the  physi- 
cian, unequivocal  want  of  experience  or  indecision. 

The  number  of  remedies  being  infinite  and  that  of  the  indica- 
tions limited,  it  results  that  each  of  the  latter  may  be  fulfilled  by 
various  remedies,  from  which  the  preferable  one  should  be  selected 

*  As  Bayle  has  remarked,  the  treatment  should  not  be  confounded  with  the 
remedy.  Treatment  is  not  the  employment  of  a  certain  remedy  in  a  given  disease, 
but  the  method  of  combatting  that  disease,  by  fulfilling,  in  the  manner  considered 
most  proper,  a  certain  indication  Remedies  may  vary  according  to  situation,  the 
age  in  which  we  live,  and  even  fashion ,  and  yet  the  treatment  be  the  same. 


428  THERAPEUTICS. 

and  administered  in  forms  and  doses  varying  according  to  a  mul- 
titude of  circumstances,  and  consequently  incapable  of  previous 
determination.  Therapeutics  are  less  susceptible  of  mathematical 
precision  in  this  respect,  than  all  the  other  branches  of  medicine. 
When  blood-letting  is  indicated,  for  instance,  it  is  impossible  that 
all  physicians  should  be  able  to  declare  the  number  of  times  that 
it  will  be  practised,  and  the  precise  quantity  of  blood  that  will  be 
drawn.  In  a  disease  where  one  would  prescribe  infusion  of  cin- 
chona, another  will  prefer  the  decoction,  powder,  or  extract ;  one 
will  use  serpentaria  in  a  case  where  another  will  order  angelica 
or  cascarilla ;  all,  however,  will  pursue  the  same  treatment  and 
perceive  the  same  indication ;  the  only  difference  will  be  in  the 
mode  of  its  fulfilment. 

The  forms  in  which  medicines  are  administered  are  extremely 
various.  Some  are  given  in  the  solid  state,  others  in  the  form  of 
gas,  or  of  vapor,  but  the  majority  are  liquid.  They  are  some- 
times applied  externally ;  most  frequently,  however,  they  are 
introduced  into  the  interior  of  the  body,  and  particularly  into  the 
digestive  canal,  whence  they  are  absorbed  into  the  system. 

Certain  medicaments  are  exhibited  singly,  others  in  a  state  of 
combination  with  different  substances,  which  at  one  time  augment 
or  modify  their  action,  at  another  merely  serve  as  their  vehicle. 
The  preparation  and  preservation  of  medicines  are  the  peculiar 
province  of  pharmacy.* 

The  dose  of  medicines  must  be  regulated  by  the  energy  of  the 
active  principles  they  contain,  also  by  the  proportion  of  those 
principles,  which  sometimes  varies,  f  the  patient's  age  and  suscep- 
tibility, the  kind  of  disease,  and  the  effect  desired ;  it  should  also 
vary  relatively  to  the  time  during  which  the  medicine  has  been 
administered  ;  habit  diminishes  the  power  of  medicines,  as  it  does 
that  of  morbific  causes,  and  it  is  necessary,  after  a  certain  time, 
to  increase  the  doses,  by  a  methodical  progression,  to  change 
their  mode  of  preparation,  or  even  to  resort  to  other  remedies, 
when  several  will  fulfil,  equally  well,  the  same  indication. 


SECTION    SECOND. 
General  or  Hygienic  Means. 

Hygiene  J  is  that  branch  of  medicine  whose  purpose  is  the  pre- 
servation of  health  and  the  prevention  of  disease.  Whatever 
conduces  to  this  double  result  may  be  classed  with  hygienic 
means. 

If  hygiene  may  be  termed  the  medicine  of  the  healthy,  hygienic 

*  <J>u(>j/axov,  a  medicine. 

f  A  mass  of  opium,  or  a  portion  of  extract  of  nux  vomica,  may  differ  so 
much  in  this  respect,  that  the  same  dose,  taken  from  the  new  specimen,  shall 
produce  toxical  symptoms. 

\  'Yyiiia,  health. 


THERAPEUTICS.  429 

means  are  as  applicable  and  necessary  to  the  diseased  as  to  those 
in  health ;  the  latter  may,  sometimes,  dispense  with  them  with 
impunity ;  the  former  cannot. 

Not  only  are  hygienic  means  very  useful  in  diseases,  but  even 
more  so  than  any  medicines,  properly  so  termed.  The  efficacy  of 
many  remedies  may  be  doubtful,  that  of  hygienic  means  cannot 
be  contested.  By  their  aid  alone,  without  medication,  the  majority 
of  acute  diseases  may  terminate  favorably ;  without  their  concur- 
rence the  most  clearly  indicated  medicines  will  always  be  insuffi- 
cient; this  is  not  mere  conjecture,  but  a  truth  confirmed  by  the 
past  and  present  observation  of  innumerable  facts.  In  places 
where  there  are  no  physicians,  and  where,  consequently,  there  is 
little,  or,  as  too  frequently  happens,  unsuitable  medication,  nature, 
assisted  by  the  hygienic  means  that  good  sense  suggests,  in  the 
majority  of  cases  not  only  conquers  the  disease,  but  overcomes 
also  the  aggravating  influence  of  improper  remedies.  In  entirely 
different  circumstances,  where  the  patients  have  medicine  and 
skilful  physicians  to  administer  it,  but  are  in  bad  hygienic  condi- 
tions, severe  diseases  terminate  in  death,  almost  without  exception, 
and  those  even  originally  far  less  dangerous,  become  fatal.  The 
crowding  of  patients  in  confined  and  ill- ventilated  apartments, 
bad  air,  entire  want  of  cleanliness,  destitution  of  linen  and  outer 
garments,  exposure  to  cold  and  rain,  errors  in  diet,  and  depression 
of  spirits,  have  constantly  produced  the  above  fatal  effect  when- 
ever their  influence  has  been  conjointly  manifested;  while  in  a 
multitude  of  acute  affections,  as  variola  discreta  and  regular 
typhus,  a  cure  has  been  effected  solely  by  the  aid  of  general  or 
hygienic  means,  no  active  remedy  having  been  employed. 

We  have  previously  pointed  out  the  necessity  of  administering 
active  remedies  singly,  or  at  least,  in  small  number  at  one  time. 
The  contrary  is  the  rule  with  hygienic  means ;  it  is,  we  may  say, 
impossible  to  combine  too  many  of  them  in  the  treatment  of  both 
acute  and  chronic  diseases. 

These  means,  although  not  precisely  similar  in  all  diseases,  are 
analogous  in  the  majority,  both  of  the  acute  and  chronic  form, 
which  enables  us  to  give  a  brief  statement  of  them,  as  constituting 
a  very  important  point  in  general  therapeutics. 


$  I.   General  Means  in  Acute  Diseases. 

A.  Circumfusa. — In  acute  diseases,  patients  should  occupy  an 
apartment  of  sufficient  size  to  avoid  deterioration  of  the  air,  and 
having  several  openings,  so  that  its  renewal  may  be  easily  ef- 
fected.—  The  temperature  of  the  room  sjiould  be  mild;  during 
summer  it  may  be  lowered  by  excluding  the  solar  light,  or  by 
aqueous  aspersion  ;  in  cold  weather  it  should  be  elevated  by 
means  of  fires. — In  winter,  a  westerly  and  southern  exposure  is 
the  best ;  a  northern  and  easterly  one  in  summer.  The  tempera- 
ture should  vary  also  with  the  nature  of  the  disease  and  the  state 


430 


THERAPEUTICS. 


of  the  animal  heat  in  the  patient.  A  dim  light  is  proper  in  dis- 
eases characterized  by  augmented  vital  action  ;  where  the  latter  is 
diminished,  a  bright  light  is  preferable.  When  the  air  of  the 
patient's  room  has  become  foul,  when  the  exhalations  or  excre- 
tions are  fetid,  and  especially  when  the  affection  from  which  he 
suffers  is  contagions,  his  own  interest,  as  well  as  that  of  the 
assistants,  demands  his  removal,  if  possible,  to  a  larger  apartment, 
frequent  renewal  of  the  air  by  opening  the  windows,  the  use  of 
ventilators,  or  aromatic  fumigations,  which,  if  they  do  not  destroy 
the  contagious  principles,  at  any  rate  communicate  a  stimulating 
property  to  the  air  which  the  patient  breathes.  Great  importance 
has  been  attached,  for  several  years,  to  fumigations  with  chlorine, 
for  the  destruction  of  miasmata  and  virus;  but  since  M.  Bousquet, 
by  repeated  trials,  has  proved  that  the  addition  of  chloride  of  soda  to 
vaccine  matter  did  not  in  the  least  change  the  contagious  property 
of  the  latter,  chlorine  has  necessarily  lost  much  of  the  reputation 
for  special  action  attributed  to  it  by  chemical  theories.* 

If  the  patient  be  in  a  small,  damp  chamber,  or  in  one  used  in 
common  with  him  by  several  others,  he  should  be  removed,  when 
a  more  suitable  place  can  be  provided,  notwithstanding  the  seem- 
ing difficulties  of  transportation.  Numerous  examples  prove,  that 
individuals  very  dangerously  ill  have  been  removed  from  hospitals 
and  carried  a  long  distance,  not  only  without  aggravation  of  the 
disease,  but  with  an  amendment  daily  more  decided  :  the  observa- 
tions of  Lindj  in  particular,  support  this  assertion. 

B.  Applicata. — The  most  scrupulous  attention  to  cleanliness  is 
absolutely  necessary  for  those  laboring  under  acute  disease ;  the 
linen,  therefore,  should  be  frequently  changed.  This  principle, 
generally  admitted  at  the  present  day,  was  long  misunderstood ; 
and  strange  to  say,  in  eruptive  and  contagious  fevers,  variola  par- 
ticularly, where  the  linen  is  constantly  soiled  with  pus,  and  con- 
sequently requires  to  be  more  frequently  changed,  the  contrary 
was  most  strenuously  advised.  There  is  no  risk  in  changing  the 
linen,  provided  it  be  not  too  often  repeated  and  fatigue  be  not 
induced  :  it  may  even  be  done,  with  proper  precautions,  during 
perspiration, f  when  chills  are  usually  apprehended. 

*  Fumigations  with  chlorine  are,  however,  spoken  of  in  the  most  commenda- 
tory terms  by  the  best  authorities  ;  the  disinfecting  property  it  possesses  is  of 
so  great  service  and  such  universal  application,  that  it  must  necessarily  always 
be  appreciated.  Thomson  styles  it  the  most  efficacious  means  of  fumigation. 
(Management  of  the  Sick  Room,  p.  275,  Amer.  Edit.)  Perejra  says,  "  as  a 
fumigating  agent,  disinfectant,  and  antiseptic,  chlorine,  I  believe,  stands  un- 
rivalled." (Mat.  Med.  and  Therap,  vol.  i.  p.  219,  Amer.  Edit.)  The  appear- 
ance of  epidemic  cholera  or. yellow  fever,  notwithstanding  its  profuse  employ- 
ment, (as  mentioned  by  Trousseau  and  Pidoux  ; —  Therapeut.,  etc.,  art.  Chlore,) 
hardly  prove,  as  these  authors  assert,  its  inutility  in  epidemics:  can  we  declare 
that  the  diseases  would  not  have  spread  more  widely  or  have  caused  greater 
mortality,  if  it  had  not  been  used]  These  authors  do  not,  of  course,  deny  its 
disinfecting  qualities.  —  TRANS. 

f  These  precautions  consist  in  passing  very  warm  napkins  beneath  the  moist- 


THERAPEUTICS.  431 

Beds  used  by  the  sick  require  a  certain  degree  of  attention.  The 
wool  mattress  is  most  commonly  employed ;  one  filled  with  hair 
would  be  preferable  in  hot  weather,  for  those  affected  with  nephri- 
tis, haemorrhage,  or  sanguineous  congestion  of  the  pelvic  viscera  : 
patients  should  never  be  allowed  to  lie  upon  feather  beds.  It  will 
often  be  necessary  to  protect  the  bed,  either  with  substances  suita- 
ble for  the  reception  of  the  excretions,  or  by  means  of  cloth  imper- 
meable by  fluids;  *  cushions  are  sometimes  needed,  so  arranged  as 
to  relieve  certain  parts  from  injurious  pressure.  The  arrangement 
and  position  of  the  bed  should  conform  to  the  circumstances  of  the 
disease  :  if  constant  dorsal  decubitus  be  requisite,  the  bed  should 
be  on  a  horizontal  plane ;  in  those  affected  or  threatened  with 
cerebral  congestion,  it  should  be  so  inclined  that  the  head  may  be 
much  higher  than  the  rest  of  the  body.  Many  kinds  of  mechani- 
cal beds  have  been  invented,  for  the  purpose  of  elevating  the  body, 
removing  pressure  from  certain  parts,  or  passing  a  bed-pan  more 
readily  beneath  the  patient,  etc.;  these  beds  are  particularly  useful 
in  fractures  of  the  lower  limbs. 

The  application  of  hot  napkins  over  the  whole  body  or  to  par- 
ticular regions,  in  cases  of  general  or  partial  chill,  and  the  use  of 
globes  or  tin  vessels  containing  hot  water,  etc.,  should  also  be 
classed  among  the  general  means. 

C.  Ingesta.  —  The  use  of  food  and  drinks  is  highly  important 
in  acute  diseases.  There  are  two  inconveniences,  equally  great, 
that  should  both  be  carefully  avoided,  viz.,  too  abundant  and  too 
restricted  nourishment.  Ramazzini  said  very  justly,  that  the 
poor  often  died  from  repletion,  when  ill,  and  the  rich  from  the 
effects  of  the  too  severe  diet  to  which  they  were  restricted. 
Hippocrates  thought  it  less  dangerous  to  slightly  exceed  the  neces- 
sary amount  of  nourishment,  than  to  enjoin  too  strict  abstinence. 
The  proper  medium  should  be  sought  for,  in  acute  disease,  all  solid 
food  being  proscribed,  but  allowing,  (when  febrile  action  is  not 
very  intense  and  the  patient  expresses  a  desire  for  them,)  slightly 
nutritious  drinks,  as  veal,  chicken  or  frog  broth,  and  even  certain 
ripe  fruits,  a  few  grapes  or  some  slices  of  orange,  of  which  the 
juice  only  should  be  swallowed ;  but  during  the  period  of  violence, 
(chap.  viii.  p.  235,)  the  diet  should  be  more  restricted,  and,  most 

ened  body  linen,  in  which  the  legs,  thighs,  abdomen,  chest,  and  even  the  neck, 
should  be  successively  enveloped,  so  that  when  the  moist  linen  is  removed  in 
order  that  dry  may  be  substituted,  the  patient  may  be  completely  covered  by  the 
warm  and  dry  clothes  :  the  arms  alone  are  momentarily  exposed  to  the  air;  but 
the  rest  of  the  body  is  protected. 

*  The  great  degree  of  perfection  attained  in  the  fabrication  of  caoutchouc,  has 
proved  a  source  not  only  of  convenience  but  of  great  comfort  to  the  healthy  as 
well  as  the  sick  :  the  variety  of  uses  to  which  it  is  now  applied  is  almost  in- 
finite ;  from  beds,  pillows,  cushions,  and  portable  baths,  down  to  far  more 
minute  and  fanciful  articles,  it  is  seemingly  well  adapted  to  all.  In  surgery  and 
practical  midwifery,  for  the  sake  of  cleanliness  alone,  it  is  highly  valuable  ; 
also  in  irrigation  of  different  parts  of  the  body,  for  the  purpose  of  protecting  the 
bed-linen,  etc.  —  TRANS. 


432  THERAPEUTICS. 

frequently,  complete  abstinence  should  be  enjoined ;  "  the  unseason- 
able ingestion  of  food,"  remarks  a  celebrated  physician,  "nourishes 
the  disease  and  not  the  patient."  During  the  period  of  decline,  its 
use  should  be  gradually  resumed. 

D.  Excreta. — The  immediate  removal  of  excreted  matters  from 
the  sick  room  and  from  the  patient's  body,  is  of  the  greatest  im- 
portance during  acute  disease  :  the  perspiration,  when  it  cools  upon 
the  body,  is  highly  injurious ;  the  urine  and  faeces,  already  modi- 
fied by  the  disease  and  liable  to  rapid  putrefaction,  communicate 
noxious  properties  to  the  air ;  matters  which  are  vomited  excite 
retching  both  by  their  appearance  and  odor.     When  the  urine  and 
faeces  are  excreted  involuntarily,   still  worse  results  may  follow 
their  contact  with  the  patient's  body :  they  may  be  absorbed  by 
the  skin,  or  may  rapidly  determine  either  a  pustular  eruption  or 
excoriation  of  the  sacral  integuments,  and  excite  the  formation  of 
eschars,  which  are  always  dangerous  and  often  fatal. 

E.  Acta.  —  Rest  and  nearly  constant  confinement  to  bed  is  gen- 
erally advised  in  acute  diseases  :  patients  are  benefitted,  however, 
by  daily  removal  from  one  bed  to  another,  or  by  being  seated  in  an 
armchair,  according  to  their  strength,  where  they  may  remain  until 
fatigue  or  uncomfortable  sensations  oblige  them  to  resume  their 
former  position.     Sydenham  advised  that  patients  should  be  re- 
moved from  bed  daily;  he  considered  this  a  preventive  of,  and  a 
remedy  for,  delirium.    We  have  previously  seen  that  passive  exer- 
cise, and  even  transportation  for  a  long  distance,  was  beneficial  to 
fever-patients:    it  is  possible  that  this  means,  (whose  beneficial 
effects  have  been  frequently  proved  by  chance  or  necessity,)  may 
have  been  too  generally  neglected. 

The  position  of  patients  too  feeble  to  move  without  assistance, 
should  be  frequently  changed ;  negligence  in  this  respect  almost 
necessarily  induces  the  formation  of  eschars  upon  parts  exposed  to 
compression,  and  all  their  disastrous  consequences. 

Sleep  is  generally  favorable  in  acute  diseases:  consequently, 
everything  likely  to  act  powerfully  upon  the  patient's  mind  or 
senses,  and  thereby  prevent  it,  should  he  avoided :  for  the  same 
reason,  sleep  should  not  be  interrupted  needlessly,  either  for  the 
administration  of  remedies  or  any  other  purpose,  except  it  have 
been  very  prolonged,  or  there  be  urgent  necessity  for  taking  medi- 
cine. When  sleep  does  not  take  place  naturally,  it  may  sometimes 
be  induced,  by  raising  the  patient  for  a  few  moments  and  arranging 
his  bed  before  replacing  him ;  when  this  is  insufficient,  if  there  be 
no  counter  indication,  a  soporific  may  be  prescribed. 

Ft  Percepta.  — The  sensations,  moral  affections  and  intellectual 
functions  demand  the  special  attention  of  the  physician.  We  have 
seen  in  what  cases  the  presence  of  light  is  favorable  or  prejudicial  : 
noises,  and  particularly  all  sorts  of  conversation,  are  nearly  always 
injurious  in  the  sick  room :  whispering  often  causes  apprehension 


THERAPEUTICS.  433 

in  the  patient ;  loud  talking  fatigues  him.  Strong  and  penetrating 
odors  are  generally  dangerous  in  inflammatory  diseases,  but  may 
be  serviceable  in  adynamic  affections  and  certain  neuroses. 

The  influence  of  the  passions  upon  the  progress  of  diseases  is  so 
powerful,  that  nothing,  which  will  give  them  a  favorable  direction, 
should  be  neglected.     For  this  reason  the  physician  should  put  in 
requisition  all  proper  means  for  securing  and  retaining  the  patient's 
entire  confidence,  and  be  on  his  guard  continually  that  nothing  in 
his  conversation  or  actions  impair  it.     By  listening  to  him  very 
attentively,  and  expressing  a  particular  interest  in  his  case,  the 
first  object  may  be  attained.     Whatever  may  be  his  opinion  as  to 
the  result  of  the  disease,  a  favorable  prognosis  should  always  be 
given  in  presence  of  the  patient ;  he  should  be  accosted  confidently, 
and  calmness  maintained  while  with  him,  even  where  there  is 
every  reason  to  apprehend  the  greatest  danger ;  no  inconsiderate 
word,  no  unguarded  gesture,  no  alteration  of  countenance  should 
lead  the  patient  to  suspect,  in  the  least,  the  peril  by  which  he  is 
threatened.     Those  who  remain  with  him  should  be  advised  to 
show  no  anxiety  whatever ;  and,  for  this  reason,  the  extent  of  the 
danger  should  not  be  disclosed  to  those  who  might  not  have  the 
resolution  or  intelligence  requisite  for  concealing  it.     There  are 
patients  who  constantly  urge  their  physician  to  tell  them  whether 
they  are  in  danger,  protesting  that  they  have  no  fear  of  death ; 
but  this  very  assertion,  and  particularly  their  eagerness  to  know 
the  probable  termination  of  their  disease,  proves  that  they  are  far 
from  being  resigned  :  the  physician  should  be  on  his  guard  against 
these  importunities.     Men  who  have  been  accustomed  to  brave 
death  under  circumstances  where  they  could  perish  gloriously, 
have  been  observed  to  quail  at  the  idea  of  the  danger  which  threat- 
ened them  in  sickness,  and  to  lose  all  courage  when  their  inevitable 
death  was  announced.     A  truly  philosophical,  and  still  more,  a 
religious  spirit,  may  impart  to  some,   the  firmness  necessary  for 
receiving  with  calmness  the  announcement  of  their  approaching 
death  ;  but  these  few  exceptions  do  not  destroy  the  common  rule  : 
the  fear  of  death  generally  adds  to  the  gravity  of  serious  disease, 
and  the  physician  who  permits  a  patient  to  suspect  the  danger  of 
his  position,  lessens  the  chances  of  cure.     He  who  announces  to  a 
patient  that  his  disease  is  necessarily  fatal,  will  be  compelled  to 
reproach  himself  not  only  for  shortening  the  life  which  he  should 
have  endeavored  to  prolong,  but  also  for  bringing  affliction  and 
despair  to  those  whom  he  should  console  and  encourage. 

All  mental  excitement  is  injurious  in  acute  affections :  patients 
should  consequently  be  restrained,  if  necessary,  from  exposing 
themselves  to  its  effects;  most  frequently,  however,  they  have 
neither  the  wish  nor  the  power  to  do  so,  and  it  will  suffice  for  the 
fulfilment  of  this  indication,  to  recommend  those  in  communication 
with  them  to  say  nothing  in  their  presence  which  might  excite 
serious  reflection  or  profound  meditation. 
37 


434  THERAPEUTICS. 


$  II.     General  Means  in  Chronic  Diseases. 

i 

Hygienic  means  are  quite  as  useful  in  chronic  as  in  acute  dis- 
eases. Change  of  habitation  and  of  climate,  travel  by  land  and  sea, 
frictions,  cold  and  warm  bathing,  the  form  and  texture  of  the  gar- 
ments, the  number  of  meals  and  the  intervals  between  them,  the 
choice  and  quantity  of  food  and  drinks,  active  and  passive  exercise, 
walking,  running,  equitation  and  amusements  of  every  description, 
are  the  principal  hygienic  means  recommended,  with  peculiar  mod- 
ifications, in  the  course  of  chronic  diseases :  in  very  many  such 
affections,  their  action  is  infinitely  superior  to  that  of  medication  in 
the  usual  acceptation  of  the  term.  In  nervous  affections  particu- 
larly, especially  those  dependent  upon  moral  causes,  in  those  vari- 
ous derangements  of  the  digestive  organs,  so  frequently  occurring, 
and  so  long  and  improperly  confounded  under  the  common  denom- 
ination of  gastritis,  what  numberless  resources  are  found  by  the 
physician  in  the  methodical  employment  of  hygienic  means,  and 
particularly  in  a  more  proper  distribution  of  the  time  allotted  to 
mental  and  physical  exercise,  in  a  greater  regularity  of  the  meals, 
and  in  that  thorough  change  of  all  the  habits  effected  by  journeys 
or  residence  in  a  different  climate.  The  patient  who  passes  the 
winter  in  a  warm  climate,  finds  other  circumstances  favorable  to 
health,  besides  the  mere  amelioration  of  the  atmosphere :  his  hy- 
gienic condition  becomes  totally  different.  If,  for  example,  he 
leaves  Paris  for  Pau,  Hieres  or  Pisa,  he  not  only  enjoys  a  milder 
climate,  but  the  air  differs  in  many  other  respects  from  that  he 
habitually  respires  ;  his  food  and  drinks  will  be  of  different  quali- 
ty ;  his  secretions  will  be  modified  ;  his  hours  for  taking  food,  for 
sleep  and  waking  will  be  changed ;  his  walks,  his  physical  and 
intellectual  occupations,  society  and  thoughts  will  be  unlike  those 
to  which  he  has  been  accustomed ;  his  clothing,  even,  will  undergo 
slight  modifications ;  in  short,  a  thousand  new  influences  will  affect 
him,  and  concur  in  modifying  the  organism  in  a  way  difficult  to 
describe,  but  sure  in  its  results. 

We  commenced  this  chapter  by  glancing  hastily  at  the  founda- 
tions of  therapeutical  science;  examining  afterwards  the  indica- 
tions and  the  means  for  their  fulfilment.  It  has  been  shown  that 
indications  were  not  always  evident ;  but  that,  notwithstanding 
this,  inaction  was  inadmissible  in  cases  where  the  disease  made 
daily  progress.  In  these  difficult  circumstances,  it  is  the  physician's 
duty,  after  having  collected  all  the  facts  that  can  yield  him 
any  information,  and  compared  the  case  submitted  to  his  care 
with  similar  or  analogous  cases  supplied  by  his  own  recollection  or 
the  annals  of  the  science,  to  treat  his  patient  as  he  would  wish  to 
be  treated  himself,  if  similarly  affected.  It  was  this  favorite  maxim 
of  Sydenham,  which  sustained  him  in  the  arduous  as  well  as  hon- 


NATURE    OF    DISEASE.  435 

orable  duties  of  his  profession  :  "  dEgrorum  nemo  a  me  alias  trac- 
tatus  est,  quam  egomet  tractari  cuperem,  si  mihi  ex  iisdem  morbis 
cegrotare  contingeret"*  —  M. 


CHAPTER  XX. 

NATURE    OF    DISEASE. 

HAVING  successively  considered  each  of  the  principal  subjects 
within  the  domain  of  general  pathology,  confining  ourselves  as 
far  as  possible  to  the  positive  part  of  this  science,  we  feel  con- 
strained, if  not  to  consider  in  its  whole  extent,  at  least  to  take  a 
brief  survey  of  its  hypothetical  portion,  that  we  may  become  con- 
vinced of  the  total  inefficacy  of  our  own  powers  in  guiding  us 
through  this  labyrinth,  and  thus  bringing  us  to  a  knowledge  of  the 
truth. 

We  shall  first  endeavor  to  show  what  is  understood  by  the  na- 
ture, essence  or  proximate  cause  of  diseases ;  and  afterwards,  to 
what  extent,  the  means,  which  we  have  at  our  disposal,  are  avail- 
able in  aiding  us  in  these  investigations. 

It  is  incorrect  to  suppose  that  disease  consists,  essentially  and 
entirely,  of  the  symptoms  it  exhibits,  and  the  anatomical  lesions 
revealed  after  death.  In  those  cases  of  neuralgia  in  which  no 
appreciable  lesion  is  discernible,  there  is  necessarily  some  modifica- 
tion in  the  affected  nerve,  from  which  the  pain  arises.  In  the  de- 
velopment of  a  phlegmasia  or  an  organic  degeneration,  as  tubercle 
or  cancer,  some  change  is  previously  effected  in  the  diseased  parts, 
and  this  change  has  induced  the  secondary  alterations  which,  in  one 
case,  characterize  the  inflammation,  and,  in  the  other,  the  cancer- 
ous or  tuberculous  affection.  The  latter  lesions  are  appreciable  to 
the  senses,  and  are  distinguished  by  their  apparent  characteristics ; 
but  the  primary  phenomenon  which  precedes  and  produces  them 
escapes  us,  both  because  it  occurs  in  the  most  minute  parts  of  the 
organization,  and  because  the  structure,  and,  consequently,  the 
intimate  action  of  these  parts,  not  only  in  man,  but  in  all  living 
beings,  to  whatever  kingdom  they  belong,  is  beyond  our  means  of 
investigation. 

We  are  aware  that  skilful  anatomists,  by  works  that  deserve  the 
highest  praise,  are  daily  extending  this  branch  of  knowledge ;  that, 
by  the  most  minute  injections  and  the  most  delicate  dissections 
they  are  enabled  to  trace,  in  the  tissue  of  organs,  the  course  of  the 
vessels  and  nerves,  further  than  any  who  have  preceded  them. 
But,  without  referring  to  the  legitimate  doubts  which  may  and 
indeed  must  arise  respecting  the  accuracy  of  these  results  in 

*  SYDENHAM,  Opera,  torn.  i.  p.  77. 


436  NATURE    OF    DISEASE. 

microscopical  anatomy,  the  continual  subjects  of  dispute  and 
contradiction  among  those  devoted  to  these  labors,  it  should  be 
recollected  that  the  difficulty  is  but  farther  removed,  that  it  still 
exists,  and  that  if  it  be  possible  to  show  by  injections  the  ultimate 
arterial  ramifications,  with  the  secretory  and  excretory  vessels  of 
the  kidneys,  pancreas  and  liver,  we  still  remain  ignorant  of  the 
structure  and  action  of  these  vessels,  in  the  mysterious  mechanism 
of  the  formation  of  the  urine,  bile  and  pancreatic  fluid.  If  it  be 
impossible,  then,  to  distinguish  the  intimate  texture  of  those  parts 
in  their  healthy  condition,  there  is  a  still  stronger  reason  for  recog- 
nizing the  impossibility  of  appreciating,  in  disease,  the  intimate 
modifications  which  occur  in  these  delicate  parts,  whose  regular 
action  is  to  us  unintelligible,  and  whose  organization,  which  death 
enables  us  to  examine  with  all  our  means  of  investigation,  is  no 
less  inexplicable.  The  history  of  medicine  affords  but  too  many 
proofs  in  support  of  this  opinion. 

This  absolute  ignorance  in  regard  to  the  peculiar  modifications 
of  the  organism  in  the  production  of  disease,  extends  also  to  each 
of  its  successive  periods,  as  is  evident  if  we  but  attempt  to  leave  the 
domain  of  secondary  phenomena,  for  the  purpose  of  investigating 
primary  facts.  Thus,  we  are  acquainted  with  the  conditions 
necessary  to  the  production  of  intermittent  fevers,  but  are  unable 
to  discover  the  mechanism  of  their  production  and  the  return  of 
their  paroxysms  ;  we  see,  in  acute  diseases,  successive  periods  of  in- 
crease, acme  and  decline;  we  appreciate  the  successive  changes  pre- 
sented by  the  symptoms  in  each  of  these  periods,  but  the  discovery 
of  the  power  which  presides  over  these  various  changes  escapes  all 
our  efforts.  Farther,  when  by  the  aid  of  means  as  energetic  as 
quinine,  we  are  enabled  to  suspend,  on  any  given  day  and  hour, 
the  course  of  the  disease,  we  must  admit  that  we  are  completely 
ignorant,  both  of  its  peculiar  nature  and  the  action  of  the  success- 
ful remedy.  In  short,  health  and  disease,  life  and  death,  subjects 
so  productive,  in  their  sensible  phenomena,  of  meditation  and  study, 
are,  in  regard  to  their  primary  causes  or  nature,  incomprehensible 
mysteries. 

Physicians  of  every  age  have  nevertheless  attempted  to  discover 
the  intimate  nature  of  diseases :  some  have  followed,  in  these 
difficult  efforts  to  proceed  from  the  known  to  the  unknown,  a  course 
apparently  methodical.  They  supposed  that,  by  carefully  consid- 
ering the  causes  which  produce  the  disease,  its  apparent  phenom- 
ena, the  circumstances  which  modify  its  course,  and  the  accom- 
panying organic  alterations,  they  should  be  able  to  ascertain  the 
intermediate  mode  of  action  between  the  effects  and  causes,  and 
discover  the  peculiar  change  which  precedes  and  induces  the  sec- 
ondary modification.  But  among  those  who  have  undertaken 
these  obscure  researches,  many  have  followed  a  more  adventurous 
course.  Instead  of  deducing  their  opinions  from  observations, 
these  did  not  hesitate  to  modify  facts  in  order  to  preserve  their  hy- 
potheses, and  to  overthrow  therapeutics  in  rendering  it  conformable 
to  their  theories :  their  proselytes  were  thus  led  into  a  double  error ; 


NATURE    OF    DISEASE.  437 

on  the  one  hand,  the  path  of  observation  was  forsaken,  and  on  the 
other,  an  erroneous  and  dangerous  method  of  treatment  was  incul- 
cated. There  have  been  at  the  same  time,  however,  persons  of 
sound  judgment  and  profound  sagacity,  who,  in  indulging  in  these 
hazardous  speculations,  have,  themselves,  placed  a  proper  estimate 
upon  their  own  conjectures ;  their  only  object  in  proposing  them 
having  been  to  pay  the  taste  of  their  contemporaries  a  necessary 
tribute,  without  which  their  works  might  not  have  been  welcomed. 
It  was  thus  with  Sydenham,  who,  by  a  reflection  on  himself, 
acknowledged  the  insufficiency  of  his  own  theories,  by  adding  that 
in  regard  to  practice,  he  had  advanced  nothing,  the  truth  of  which 
had  not  been  confirmed  by  his  own  experience.  "  I  have  directed 
all  my  efforts,"  he  farther  adds,  u  to  the  elucidation  of  the  treat- 
ment of  diseases,  being  persuaded  that  he  who  can  point  out  a 
method  of  cure  for  the  most  trivial  affection,  deserves  higher  praise 
than  he  who  becomes  distinguished  by  his  powers  of  reasoning,  and 
those  pompous  subtleties  which  are  as  unprofitable  to  the  phy- 
sician, in  the  cure  of  disease,  as  the  knowledge  of  music  to  an 
architect  in  the  construction  of  a  building."* 

The  results  of  researches  undertaken  for  the  purpose  of  acquir- 
ing knowledge  which  is  unattainable,  have  been  and  must  be 
widely  different :  we  cannot  then  be  surprised  at  the  diversity  in 
the  theories  which  have  been  proposed  in  regard  to  the  nature  of 
disease ;  it  would  be,  on  the  contrary,  a  matter  of  astonishment 
were  this  not  the  case.  Among  these  hypotheses,  some  are  based 
upon  alterations  of  the  humors,  others  upon  those  of  the  solid  parts 
of  the  body,  so  that  they  may  be  referred  to  two  great  divisions, 
humorism  and  solidism,  each  the  subject  of  opinions  as  numerous 
as  the  followers  of  these  two  theories. 

The  humorists,  who  made  the  essence  of  disease  to  consist  in 
the  alterations  of  the  fluids,  applied,  to  most  affections,  terms  in 
accordance  with  their  theories.  Instead  of  saying  that  a  disease 
affected  the  liver,  or  the  circulatory  organs  of  the  blood  or  lymph, 
they  placed  its  seat  in  the  fluids  themselves  contained  in  these  or- 
gans. The  morbific  causes  always  affected  the  fluids;  the  aliments 
elaborated  by  the  stomach,  and  converted  into  chyle,  modified  the 
qualities  of  the  blood ;  a  similar  effect  was  produced  by  the  action 
of  poisons,  virus,  etc.  In  their  exposition  of  symptoms,  their  lan- 
guage was  still  in  conformity  with  this  theory;  the  color  and  con- 
sistence of  the  blood,  mucus,  alvine  matters,  urine  and  pus,  claimed 
their  particular  attention  ;  other  symptoms  were  hardly  alluded  to, 
or  were  attached  to  their  favorite  nomenclature  by  means  of  col- 
lective names.  It  was  from  the  alterations  of  the  humors  that 
they  explained  the  connection  and  succession  of  symptoms.  They 
designated,  by  the  terms,  crudity,  coction  and  evacuation,  the  three 
principal  periods  of  diseases,  according  to  the  condition  of  the  mor- 
bific matter.  In  the  first  period,  this  matter,  endowed  with  all  its 
deleterious  power,  not  having  undergone  any  alteration,  still 

*  SYDENHAM,  Opera  omnia,  torn.  i.  p.  77. 
37* 


438  NATURE  OF  DISEASE. 

preserved  its  crudity ;  in  the  second,  in  which  coction  was  effected, 
nature  gradually  gained  the  advantage ;  and,  finally,  in  the  third, 
the  material  principle,  rendered  movable,  was  evacuated  with  the 
urine,  sweat,  fsecal  matters,  or  by  some  other  means,  and  the  equilib- 
rium was  restored.  When  no  evacuation  took  place,  they  sup- 
posed that  the  morbific  matter,  after  having  undergone  the  necessary 
elaboration,  became  assimilated  with  the  natural  humors,  and  from 
that  moment  became  harmless;  coction  was  perfect  or  imperfect; 
and  the  transformation  of  one  disease  into  another  was  readily 
explained  by  means  of  the  transfer  or  emigration  of  the  humoral 
principle  which  presided  over  its  development.  It  was  particularly 
from  the  inspection  of  evacuated  fluids  that  they  formed  conclu- 
sions with  regard  to  the  termination  and  duration  of  diseases ;  the 
urine,  particularly,  furnished  signs  to  which  they  attached  much 
importance.  They  were  confirmed  in  their  opinion  by  necroscopy ; 
the  redness  and  swelling  of  inflamed  parts,  they  regarded  as  the 
effect  of  an  accumulation  of  blood ;  dropsy,  as  the  dissolution  of 
this  fluid ;  tubercular  degeneration  they  considered  but  a  thick- 
ening of  lymph;  and  most  other  organic  alterations  but  obstructions 
produced  by  the  consistence  and  coagulation  of  fluids.  The  thera- 
peutical indications  were  in  accordance  with  the  other  points  of  the 
humoral  doctrine.  Bleeding  was  practised  in  order  that  the  blood 
might  be  renewed,  to  diminish  its  viscidity,  or  to  remove  a  portion 
of  the  morbific  matter  with  which  it  was  mixed ;  purging,  sweat- 
ing, and  diuresis  were  excited  for  similar  purposes ;  in  short,  all 
the  indications  consisted  in  changing  the  quantity  or  quality  of  the 
fluids,  or  determining  their  afflux  towards  certain  organs. 

The  solidists  regarded  the  same  subjects  in  a  totally  different 
point  of  view :  according  to  this  class  of  philosophers,  the  fluids 
play  but  a  passive  part  in  the  phenomena  of  life ;  deprived  of  vi- 
tality, sensibility  and  contractility,  they  are  entirely  subordinate  to 
the  action  of  the  sensible  and  contractile  organs  containing  them. 
Disease,  consequently,  resides  essentially  in  the  solids,  which  are 
alone  capable  of  receiving  the  impression  of  morbific  causes,  and  of 
furnishing  important  symptoms.  Sympathy,  whose  seat  is  the 
nervous  system,  satisfactorily  explains  the  connection  between  the 
symptoms  and  the  general  disturbance  which  accompanies  any  local 
affection.  Metastasis  and  crises  are.  in  their  opinion,  more  favorable 
to  their  own  theory,  than  to  that  of  the  humorists.  "  Indeed,  the 
discharge  of  a  small  quantity  of  blood,  urine,  fsecal  matters  or  sweat, 
is  insufficient  to  explain  the  passage  from  disease  to  health,  inas- 
much as  the  presence  of  these  in  the  economy  is  incapable  of  de- 
ranging the  regularity  of  the  functions  ;  there  is,  according  to  them, 
a  transfer  of  action*  or  irritation^  and  not  of  fluid;  it  is  much 
easier,  seriously  say  they,  for  nature  to  transfer  one  than  the  other. 
The  organs,  in  disease,  preserve  or  acquire  certain  relations,  by 
virtue  of  which  they  transmit  to  each  other  their  impressions;  the 

*  SPRENGEL,  Pathol.  general. 

•j-  MA  RAN  DEL,  These  sur  les  Irritations. 


NATURE    OF    DISEASE.  439 

irritation  which  affects  any  organ  for  many  days,  may  thus  be 
transmitted  to  some  other :  the  first  resumes  its  functions,  and  if 
the  transmitted  affection  be  slight,  health  is  restored ;  if  it  be  grave, 
it  constitutes  metastasis.  The  most  convincing  proof  that  there  is 
simply  a  transport  of  irritation,  is,  that  metastases  and  crises  are 
sometimes  observed,  which  consist  solely  in  the  transfer  of  pain  or 
some  other  nervous  phenomenon,  without  the  exhalation  of  any 
fluid,  as  is  noticed  in  the  neuroses  and  rheumatic  affections.  Finally, 
in  cases  where  there  is  an  afflux  of  fluid  towards  an  organ,  the  quali- 
ties of  this  fluid  present  the  greatest  variety ;  the  only  constant  cir- 
cumstance is  an  irritation  which  precedes  it,  and  which  is  character- 
ized by  pruritus,  pain,  heat,  swelling,  redness  or  some  other  analo- 
gous change  in  the  part,  where  the  crisis  or  metastasis  takes  place. 
In  regard  to  the  diagnostic  or  prognostic  signs  presented  by  the 
fluids,  they  are  always  of  secondary  importance,  and  the  results  of 
necroscopy,  which  so  clearly  show  the  alterations  of  the  solid  parts, 
prove  how  slender  is  the  basis  upon  which  humoral  pathology  is 
founded.  Finally,  the  most  accurate  indications  arise  from  changes 
in  the  external  appearance,  movements  and  heat,  and  in  the  organs 
of  digestion,  respiration  and  circulation ;  all  these  symptoms  are 
evidently  furnished  by  the  solids,  to  which  these  functions  be- 
long." 

Such  are  the  principal  points  of  the  doctrines  of  humorism  and 
solidism :  we  have  thought  proper  to  present  them  together,  with- 
out adding  any  remark.  The  old  doctrine  of  humorism  was  based 
upon  inaccurate  data,  furnished  by  the  science  of  chemistry  when 
in  its  infancy  ;  upon  a  theory  totally  false,  in  which,  with  an  entire 
disregard  of  the  vital  influence,  the  alterations  in  the  humors  were 
attributed  to  a  fermentation  or  putrifaction  analogous  to  what 
takes  place  without  the  body.  To  show  the  absurdity  of  this  sys- 
tem, and  to  overthrow  it,  was  by  no  means  a  difficult  task.  The 
brilliant  physiology  of  Bichat,  the  ardor  with  which  Pinel  attacked 
the  humoral  doctrine,  the  zeal  with  which  the  study  of  pathologi- 
cal anatomy  was  prosecuted,  together  with  the  prejudice  in  favor 
of  solidism^  which  naturally  arose,  all  these  circumstances  rapidly 
effected  a  complete  revolution  in  the  science,  and  the  entire  medical 
generation  of  this  period  and  that  immediately  following,  adopted 
in  reality,  if  not  in  principle,  an  exclusive  solidism,  from  which 
arose  and  became  developed  the  system  of  irritation.  All  influence 
of  the  fluids  in  the  development  of  diseases  was  rejected,  and  all 
the  phenomena  of  life,  in  disease  as  well  as  health,  were  made  to 
depend  immediately  upon  the  solids. 

We  were  among  the  first,  in  1817,  to  contradict  this  opinion,* 
and  to  endeavor  to  attach  all  the  importance  to  the  fluids,  which 
they  deserve  in  the  phenomena  of  life,  whether  in  health  or  disease. 
We  attempted  to  show,  1st,  by  the  normal  composition  of  the  hu- 
man body,  in  which  the  fluids  exist  in  an  incomparably  larger 
proportion  than  the  solids ;  2dly,  by  the  alterations  revealed  by 

*•  First  edition  of  this  work,  1817. 


440  NATURE    OF    DISEASE. 

necroscopy  which,  in  some  cases,  exclusively  affect  the  fluids;  3dly, 
by  the  nature  of  the  various  agents  by  which  the  health  may 
become  deranged,  some  of  which,  as  the  aliments  and  drinks, 
introduced  into  the  economy  by  absorption,  evidently  modify  the 
composition  of  the  fluids ;  4thly,  by  certain  modifications  which  evi- 
dently exist  in  the  lining  fluids,  as  those  presented  by  the  blood  in 
scurvy  and  icterus,  by  the  urine  in  diabetes,  by  the  bile  in  the 
formation  of  hepatic  concretions,  etc.,  that  the  doctrine  of  solidism 
is  insufficient  to  account  for  the  phenomena  observed,  and.  sooner 
or  later,  must  yield  to  a  less  exclusive  system. 

Since  that  time,  a  great  change  has  taken  place  in  the  opinions 
of  the  medical  world.  To  the  facts  to  which  we  have  just  referred, 
others  have  been  added ;  the  diminution  of  albumen  in  the  blood 
and  its  presence  in  the  urine,  in  those  affected  with  Bright's  dis- 
ease ;  the  changes  in  the  relative  proportion  of  fibrine  and  red 
globules  in  the  blood  in  inflammatory  fevers  and  chlorotic  affec- 
tions ;  the  presence  in  this  fluid,  either  of  pus  in  certain  diseases, 
or  of  venomous  substances  in  cases  of  poisoning,  and  the  various 
modifications  in  the  milk,  urine  and  saliva,*  have  added  such  a 
multitude  of  facts  to  those  which  we  pointed  out  twenty  years  ago, 
that  an  entire  change  of  opinion  has  been  effected.  The  chemical 
and  microscopical  labors  of  many  distinguished  scientific  men, 
among  whom  may  be  mentioned  MM.  Thenard,  Bright,  Orfila, 
Dumas,  Andral,  Donne,  and  Rayer,  have  contributed  to  restore  to 
the  fluids  their  importance  in  the  phenomena  of  health  and  disease. 
It  is  possible  that  after  so  long  discrediting  the  most  manifest  alter- 
ations in  the  fluids,  we  may  be  at  present  rather  inclined  to  suspect 
their  existence  in  all  cases,  and  to  admit  them  upon  the  slightest 
indications,  and  without  sufficient  observation,  and  to  exaggerate 
their  importance  with  the  threefold  reference  to  etiology,  symptom- 
atology and  therapeutics  :  such  is  the  proneness  of  the  human 
mind  to  extremes,  and  the  difficulty,  in  all  cases,  to  maintain  a  just 
medium,  the  surest  defence  from  exaggeration  and  error. 

We  shall  not  follow  the  humorists  and  solidists  in  the  numerous 
alterations  which  they  have  supposed,  in  order  to  explain  the  na- 
ture of  diseases ;  we  shall  also  abstain  from  exposing  the  various 
systems,!  which,  from  the  earliest  ages,  have  successively  reigned 
in  the  schools.  They  are  now  abandoned,  and  will  live  only  in 

*  See  pages,  185,  186,  208,  211,  225. 

f  We  will,  however,  except  the  system  of  irritation,  since  its  followers  have, 
till  quite  recently,  been  numerous,  and  even  now  it  finds  favor  with  a  few. 

"  According  to  this  theory,  health  and  disease  are  but  different  effects  of  the 
same  principle,  that  of  irritation. 

"  A  disordered  state  of  health  is  always  owing  either  to  an  accumulation  of 
excitation  or  irritation  in  some  part,  through  the  influence  of  external  stimuli 
whose  object  is  to  maintain  the  functions,  or  to  a  deficiency  of  this  principle  in 
the  economy. 

"  The  functions  may  be  deranged  in  two  ways  ;  they  may  be  performed  with 
too  great  or  too  little  energy. 

"  Irritation  is  then  the  primary  cause  or  source  of  all  morbid  action ;  the 
phlegmasise,  haemorrhages,  neuroses,  and  degenerations  of  every  kind,  are  but  its 


NATURE    OF   DISEASE.  441 

the  history  of  the  science  ;  they  attest  the  feebleness  of  the  human 
mind  whenever  it  attempts  to  attain  a  knowledge  of  the  pri- 
mary laws  of  the  organization.  In  this,  as  in  many  other  things, 
we  must  remain  ignorant  of  what  it  was  not  intended  we  should 
know.  All  discussion  upon  insoluble  questions  is  unprofitable  and 
dangerous ;  unprofitable,  because  it  can  be  followed  by  no  satis- 
factory results  ;  dangerous,  because  it  almost  always  leads  to  error. 
When  once  we  enter  upon  the  domain  of  hypotheses  and  theories, 
it  often  becomes  impossible  for  us  to  pause,  and  if,  afterwards,  we 
attempt  to  retrace  our  steps  and  return  to  the  investigation  of  posi- 
tive subjects,  they  appear  so  cold  and  uninviting,  in  comparison 
with  the  seducing  speculations  to  which  we  have  previously  de- 
voted ourselves,  that  they  cannot  fail  to  prove  totally  devoid  of 
interest. 

Although  it  be  shown  that  the  intimate  nature  of  things  is  above 
our  comprehension,  and  although  this  truth  has  been  proclaimed 
more  widely  in  our  own,  than  any  previous  age,  there  are  neverthe- 
less persons  of  true  merit,  who  still  think  that  they  may  yet  be  able  to 
explain  the  secrets  of  nature,  and  who  have  their  proselytes.  This 
ceases  to  be  a  matter  of  surprise,  if  we  but  glance  at  the  history  of 
medicine  ;  the  human  mind  is  always  the  same,  and  may  be  judged, 
in  the  future,  by  the  past.  Systems  have  been  the  product  of  all 
ages,  and  are  still  in  process  of  formation :  they  have  had,  and 
will  continue  to  have,  their  admirers,  and  will  be  forgotten,  as 
have  been  those  which  preceded  them.  But,  if  it  be  objected  that, 
in  order  to  the  proper  treatment  of  a  disease,  its  intimate  nature 

effects,  and  cannot  be  considered  as  diseases,  unless  we  consider  suppuration  also 
an  idiopathic  affection." 

Let  us  briefly  examine  this  theory,  which  closely  resembles  those  of  Themison 
and  Brown,  and  see  to  what  extent  it  has  foundation. 

It  is  generally  supposed,  and  is,  we  believe,  incontestable,  that  all  diseases  are 
owing  to  some  change  in  the  action  of  our  organs  ;  this  intimate  change  precedes 
and  produces  all  the  alterations  of  tissue ;  so  that,  properly  speaking,  all  that  we 
call  disease  is  consecutive  to  this  change.  But  as  this  peculiar  modification 
escapes,  as  we  have  stated  in  the  preceding  chapter,  all  our  means  of  investiga- 
tion, reason  prompts  us,  this  first  truth  being  known,  to  direct  our  study  and  ob- 
servation to  the  appreciable  phenomena.  It  is  thus  that  the  progress  of  medicine 
has  been  real ;  it  has  been  retrograde  whenever  it  has  been  attempted  to  seek  the 
primary  causes ;  the  principal  defect  in  the  theory  of  irritation. 

Another  and  not  less  remarkable  error  is,  to  limit  to  two  modes  this  change  of 
action,  which  is  the  source  of  all  our  diseases.  According  to  M.  Brnussais,  the 
stimulants  have  been  either  too  powerful  or  too  feeble,  and  the  action  of  the  organs 
is  increased  or  diminished  :  now,  if  we  may  be  permitted  to  reason  upon  a  subject, 
the  knowledge  of  which  it  was  never  intended  we  should  attain,  we  might  ask  if 
it  is  not  probable  that  besides  this  increase  and  diminution  of  energy,  there  may 
also  be  a  perversion  of  action,  itself  susceptible  of  appearing  under  infinitely 
various  forms.  If  the  effects  of  this  primary  change  of  action  occur  with  number- 
less modifications,  as  is  evident  from  the  numerous  organic  alterations  which  take 
place  in  diseases,  is  it  not  natural  to  suppose  that  the  causes  which  escape  us  vary 
with  their  sensible  effects? 

These  considerations  appear  to  us  more  than  sufficient  to  demonstrate  the  uncer- 
tainty and  instability  of  the  foundation  of  the  doctrine  of  irritation.  If  this  were 
the  place  to  consider  this  system,  the  falsity  of  the  consequences  would  furnish 
additional  proofs  of  the  falsity  of  the  principle. 


442  CLASSIFICATION    OF    DISEASES. 

should  be  understood,  to  those  we  may  reply,  with  Syd&iham* 
that  all  the  acts  of  nature  are  alike  obscure,  and  that  the  Wisdom 
which  ordained  the  universe,  has  reserved  to  himself  the  knowl- 
edge of  the  laws  by  which  its  harmony  is  maintained  ;  "  but,  be- 
sides," as  this  celebrated  practitioner  remarks,  "  it  is  not  upon  a 
knowledge  of  the  first  causes  that  therapeutics  is  based,  but  rather 
upon  observation  and  experience,  which  can  and  should  alone 
guide  the  physician  in  the  practice  of  his  profession." 

We  might  have  dispensed  with  the  chapter  upon  the  nature  of 
disease,  which  but  reveals  our  own  ignorance  in  regard  to  it,  and 
teaches  us  to  abstain  from  directing  our  powerless  efforts  towards 
its  discovery ;  but  it  is  no  less  important,  in  the  study  of  the  sci- 
ence, to  point  out  the  paths  which  lead  to  error,  than  those  which 
conduct  to  a  knowledge  of  truth.  —  O. 


CHAPTER  XXI. 


CLASSIFICATION    OF    DISEASES. 

THE  classification  of  diseases,  or  nosology,^  is  that  branch  of 
medicine  whose  object  is  the  methodical  distribution  of  diseases 
into  a  certain  number  of  groups,  to  which  the  term  classes  has  been 
applied,  and  which  are  commonly  subdivided  into  orders  or  fami- 
lies, to  these  being  referred  all  the  genera  and  known  species. 
•  Felix  Plater  appears  to  have  been  the  first  to  conceive  and  carry 
into  execution,  the  idea  of  a  methodical  distribution  of  diseases. 

The  division  proposed  by  Plater  was  hardly  known,  when  Sauv- 
ages  published,  in  the  eighteenth  century,  his  Nosologie  Method- 
ique,  which  was  very  favorably  received,  and  considered  as  the 
first  work  of  its  kind.  Diseases  were  by  him  divided  into  ten 
classes,  which  he  designated  by  the  terms,  deformities,  fevers, 
phlegmasi(E,  spasms,  anhelations,  debilities,  pains,  vesanice,  Jinxes 
and  cachexies.  Each  of  these  classes  was  divided  into  several 
orders,  to  which  were  referred  a  certain  number  of  genera,  which 
presented  all  the  characters  of  the  class  and  order  to  which  they 
belonged,  and  also  characteristics  peculiar  to  themselves. 

The  classification  of  Linnceus  closely  resembled  that  of  Sauv- 
ages ;  he  added  another  class  of  diseases,  which  he  designated  by 
the  title  suppressions,  transferring  some  of  those  affections,  consid- 
ered by  Sauvages  under  the  class  of  fevers,  into  the  class  of  critical 
diseases,  or  those  characterized  by  a  brick  colored  sediment  in  the 
urine. 

*  Opera  Omnia,  torn.  i.  p.  66. 
t  Nosog,  disease  ;  Asyw,  I  collect. 


CLASSIFICATION   OF    DISEASES.  443 

Vogel,  Sagar  and  Vitel  admitted  nearly  the  same  classes,  under 
different  names. 

Cullen  reduced  the  classes  of  diseases  to  four,  viz. :  three  classes 
of  general  affections,  pyrexiae,  neuroses  and  cachexies,  and  one 
class  of  local  affections. 

Macbride  also  admitted  four  classes,  which  he  designated  by  the 
terms  general,  local,  sexual  and  puerile  diseases. 

All  these  classifications  present  so  many  defects  and  incongrui- 
ties, that  they  have  been  generally  abandoned.  Those  of  Darwin, 
Tourdes  and  Baumes  are  based  upon  theories  too  unstable  to  be 
received. 

The  classification  of  Pinel  is  far  less  objectionable  than  any  pre- 
ceding it.  This  physician  divided  diseases  into  five  classes,  viz. : 
fevers,  phlegmasice,  haemorrhages,  neuroses  and  organic  affections. 
This  classification  approaches  nearer  than  the  others  to  that  per- 
fection of  which  the  subject  is  capable.  If,  in  his  distribution  of 
diseases,  Pinel  has  sometimes  approximated  affections  which  it 
would  seem  should  be  separately  considered,  and  separated  others 
which  should  more  naturally  have  been  connected,  these  imperfec- 
tions do  not  prevent  his  nosological  system  from  holding  the  first 
rank.  Besides,  it  is  very  doubtful  if  a  nosological  classification 
can  ever  be  as  methodical,  notwithstanding  the  idea  of  Gaubius* 
as  those  of  plants  and  animals,  the  characters  of  the  latter  being 
more  defined  and  more  easily  distinguishable. 

These  different  classifications  only  comprise  those  within  the 
domain  of  medical  pathology.  Surgical  diseases  have  also  their 
classifications,  which  are  generally  established  according  to  the 
seat  rather  than  the  peculiar  forms  of  these  diseases :  some  authors 
have  also  objected  that  the  divisions  of  external  diseases,  however 
methodical  they  may  be,  should  not  be  considered  as  classifications 
properly  so  called.  It  matters  little,  however,  whether  diseases  be 
methodically  distributed  or  classed,  provided  they  be  so  presented 
as  to  render  their  exposition  the  most  easy. 

Classifications  are  not  indispensable  to  the  study  of  pathology. 
They  have  been  for  some  time  dispensed  with,  and  it  is  not  certain 
that  they  have  had  any  influence  upon  the  progress  of  the  science. 
A  good  classification,  however,  aids  and  abridges  the  study,  and 
hence  its  utility  cannot  be  questioned.  Besides,  by  presenting 
under  a  distinct  head  all  the  known  diseases,  it  leads  to  a  more 
precise  knowledge  of  their  analogies  and  differences,  and  to  a  more 
just  appreciation  of  the  value  of  general  assertions  and  points  of 
doctrine,  by  enabling  us  to  make  a  rapid  application  of  them,  to  ail 
the  groups  of  diseases,  arranged  according  to  some  order  which 
should  be  always  present  in  the  physician's  mind. 


*  Non  est  cur  disperent  medici,  fore  aliquando,  ut  ingens  morborum  humano- 
rum  numerus,  exemplo  ab  histories  naturalis  scriptoribus  petito,  in  ordinem  systeni- 
aticum  redigatur,  qui  ab  omni  hypothesi,  sectarumque  commenlis  liber,  sola  mocus 
fideli  observations,  classes,  genera,  species  exhibeat,  suis  singula  char  act  en  smi  s , 
ccrtis  manifestis,  plenis  interstincta.  —  (Institut.  Pathol.) 


444  TREATISES  ON  GENERAL  PATHOLOGY. 

Apart  from  these  advantages,  nosology  presents  serious  incon- 
veniences: the  necessity  of  dividing  all  diseases,  into  a  limited 
number  of  classes,  has  led  nosologists  to  bring  together,  in  the  same 
series,  diseases  of  a  widely  different  nature,  and  often  to  omit  those 
which  would  not  so  naturally  belong  to  the  adopted  group. 

The  different  parts  which  collectively  constitute  the  human  body 
are  subject  to  numerous  diseases,  some  of  which  are  common  to  all 
these  parts,  as  inflammation,  affections  properly  so  called,  atrophy 
and  hypertrophy,  alterations  of  secretion  and  innervation,  and, 
also,  the  lesions  produced  by  physical  and  chemical  agents;  others 
are  peculiar  to  each  of  the  organs,  affecting  their  structure  alone, 
and  having  no  analogy,  or  at  least  a  very  remote  one,  to  the  dis- 
eases of  other  parts.  Among  the  latter  affections,  may  be  men- 
tioned the  various  cutaneous  exanthemata,  apthae  and  the  diptheri- 
tic  affections,  rheumatism,  emphysema,  rachitis,  invagination, 
varix,  aneurism,  calculous  affections,  and  certain  primary  altera- 
tions of  the  fluids,  as  anemia  and  diabetes,  all  affections  differing 
from  others  in  that  they  affect  the  structure  or  composition  of  the 
solid  parts  or  fluids.  These  affections  cannot  be  properly  included 
in  our  classifications,  the  latter  being  particularly  applicable  to 
those  diseases  which  may  affect  all  parts  of  the  body. 

We  were  led,  from  these  considerations,  upon  devoting  ourselves 
more  particularly  to  the  instruction  of  pathology,  to  adopt  a  classi- 
fication only  of  those  diseases  capable  of  such  an  arrangement,  as 
the  phlegmasise,  morbid  secretions,  the  neuroses  and  common 
organic  lesions,  without  attempting  the  classification  of  those  pe- 
culiar to  the  various  parts  which  collectively  constitute  the  human 
body.  We  are  thus  enabled  to  reap  all  the  advantages  and  avoid 
all  the  inconveniences  necessarily  connected  with  the  classification 
of  diseases.  —  O. 


CHAPTER   XXII. 

PRINCIPAL    TREATISES    ON   GENERAL    PATHOLOGY. 

THE  first  notions  upon  General  Pathology  are  nearly  as  ancient 
as  medicine  itself:  they  are  found  in  the  writings  of  Hippocrates. 
His  Treatise  upon  the  Atmosphere,  Water,  and  Localities,  is  par- 
ticularly devoted  to  etiology,  and  prognosis  is  exhibited  in  many 
of  his  books  with  admirable  precision.  Hippocrates,  however, 
has  not  considered  diseases  in  an  abstract  manner.  Galen  seems 
to  be  the  first  who  conceived  this  idea. 

In  his  essay  de  Differentiis  Morborum,  this  accomplished  physi- 
cian first  gives  a  general  definition  of  disease,  and  this  definition 
is  nearly  the  one  we  have  adopted ;  he  afterwards  treats  of  its 
distinctions,  and  divides  into  three  groups  the  various  affections, 


TREATISES  ON  GENERAL  PATHOLOGY.  445 

according  as  they  are  peculiar  to  homogeneous  and  organic  parts, 
or  common  to  both;  he  subdivides  them  all  into  simple  and  com- 
plex diseases. 

In  other  works  *  he  treats  generally  of  the  causes  and  seat  of 
diseases,  of  symptoms  and  their  differences,  of  periods,  which  he 
ingeniously  compares  to  the  different  ages  of  life ;  of  types,  crises, 
and  decretory  days.  We  find  also  in  his  works  some  general 
remarks  upon  semeiol<^y  and  therapeutics.  Thus  Galen,  without 
having  written  a  special  treatise  upon  this  subject,  has  displayed 
the  principal  doctrinal  points  belonging  to  it,  in  as  many  separate 
books :  on  this  account  we  do  not  hesitate  to  consider  him  the 
founder  of  general  pathology. 

The  perusal  of  the  works  written  upon  this  branch  of  medicine 
is  peculiarly  fitted  to  confirm  this  opinion.  Not  to  mention  those 
who,  up  to  the  epoch  of  the  revival  of  literature,  had  confined 
themselves  to  the  translation  or  repetition  of  what  had  been  said 
before  their  time,  we  see  the  most  noted  physicians  of  the  later 
centuries,  as  Fernel,  Sennert,  Riviere,  and  Plempius,  doing 
nothing  more  than  to  complete,  in  a  somewhat  different  manner, 
the  plan  traced  by  Galen.  Boerhaave  himself  has  followed  a 
similar  course,  except  in  the  distribution  of  symptoms. 

The  Treatise  on  Pathology  by  Fernel  is  included  in  his  Uni- 
versal Medicine  ;  f  it  is  divided  into  two  parts  :  the  first  treats  of 
disease  in  general,  and  of  its  causes ;  the  second  of  symptoms  and 
signs.  In  the  portion  devoted  to  disease  and  health,  he  remarks 
that  each  has  a  certain  latitude,  and  that  between  these  opposite 
conditions  there  exists  an  inter  mediate  stage,  (constitutio  neutra,} 
which  participates  in  the  characteristics  of  each,  but  which  differs 
from  both ;  this  condition  may  more  nearly  resemble  health  or  dis- 
ease, or  maintain  a  medium  position  between  them.  Fernel,  in  his 
Semeiology,  treats  particularly  of  critical  signs,  dividing  them  into 
general  and  particular,  and  subdividing  them  very  methodically 
into  the  antecedent,  accompanying  and  following  signs  of  crisis. 

In  the  work  of  Sennert%  we  also  find  numerous  fundamental 
ideas.  When  speaking  of  the  symptoms  furnished  by  various 
functions,  he  examines  successively  their  abolition,  diminution, 
depravation  and  exaltation  ;  it  would  be  difficult  to  form  a  more 
convenient  division.  He  establishes,  moreover,  a  distinction  be- 
tween diseases,  according  as  they  supervene  under  ordinary  cir- 
cumstances, or  unusual  conditions:  to  these  two  divisions  he  gives 
the  names  morbi  congnd  et  incongrui. 

Lazare  Riviere,  in  his  Institutes  of  Medicine,^  treats  of  disease 

*  De  causis  liber  unus.  —  Liber  de  Locis  affectis.  —  De  symptomatum  differen- 
tiis  liber  unus. — De  symptomatum  causis  lib ri  ires.  —  De  morborum  tempo  nbvt 
liber  unus.  —  Liber  de  totius  Morbi  temponbus.  —  Liber  de  Typis.  —  Liber  </c 
Crisibus.  —  Liber  de  Diebus  decretoriis. 

f  JOANNIS  FERNELII,  Universa  Medicina.     Venitiis.  1564,  in-4°. 

|  Institutionum  Medicince,  libri  v.    Auctore  Daniele  Sennerto.    Wittebergte. 

§  LA.ZARI  RIVERII,  Opera  medico,  universa,  in.  quibus  contineiitur  Institutionum 
Mzdicarum,  libri  v.  Lugduni,  1676. 

38 


446  TREATISES  ON  GENERAL  PATHOLOGY. 

in  general ;  a  chapter  is  devoted  to  the  changes  in  disease,  and 
semeiology  is  divided  into  two  branches,  one  relating  to  diagnosis, 
the  other  to  prognosis.  The  treatises  of  Plempius*  and  Charlton\ 
contain  nothing  remarkable. 

Boerhaave,  in  his  Institutes  of  Medicine,:]:  has  devoted  a  few 
pages  only,  to  general  pathology  ;  the  concise  remarks  which  he 
has  made  upon  this  subject  have  been  the  theme  of  very  exten- 
sive commentaries.  Among  the  authors  w^ho  have  thus  labored, 
we  find  the  names  of  Haller§  and  of  Dehaen;\\  the  lectures  of 
the  latter,  collected  by  Wasserberg,  contain  all  that  is  most  inter- 
esting; but  a  more  or  less  detailed  description  of  all  diseases  is 
also  found  in  them,  and  such  a  description,  although  it  may  with 
propriety  be  treated  of  in  the  institutes  of  medicine,  is  out  of  place 
in  a  work  upon  general  pathology. 

Among  the  published  works  upon  this  subject,  the  Institutes  of 
Pathology  by  Gaubius  11  is  certainly  one  of  the  most  remarkable  ; 
we  discover,  in  many  portions,  ingenious  thoughts,  profound  reflec- 
tions, and  luminous  comparisons,  which  justify  the  favorable 
reception  accorded  to  the  work,  and  its  well  deserved  reputation 
at  the  present  day.  He  was  the  first  to  give  the  name  General 
Pathology  to  the  branch  of  medicine  of  which  we  treat. 

The  Pathological  Tables  of  Juncker**  form  a  valuable  collec- 
tion, in  which  we  find  enumerated  the  various  opinions  of  most 
authors  upon  the  principal  doctrinal  points.  The  form  of  this 
work  renders  its  perusal  fatiguing,  but  it  may  be  consulted  with 
advantage. 

The  short  treatises  of  Ludwig\\  and  Astruc  JJ  constitute  abridg- 
ments of  pathological  doctrines ;  the  latter  is  written  with  a 
degree  of  elegance  which  has  doubtless  contributed  to  the  success  it 
has  obtained. 

Since  the  commencement  of  this  century,  many  works  upon 
general  pathology  have  been  published  in  Germany;  a  few 
have  also  appeared  in  France.  Many  of  these  contain  a 

*  Vopisci  Fortunati  PLEMPII,  de  Fundamentis  Medicines,  libri  vi.  Lovanii, 
1638. 

j-  Exercitationes  Pathologic^  in  quibus  morborum  pent  omnium  natvra,  gen- 
eratio,  et  causa  ex  novis  anatomicorum  inventis  sedulb  inquiruntur,  &  Gualtero 
Charltono.  Londini,  1661. 

J  Institutiones  Medicce  in  usus  annuae.  exercitationis  domesticos  digesta,  ab 
Hermanno  Boerhaave.  Editio  ultima.  Parisiis,  1747. 

§  Hermann!  BOERHAAVII,  Preelections  academics  in  proprias  Institutiones  rei 
Medicce,  edidit  Albertus  Haller.  Gottingse,  1744. 

||  Pralectiones  Antonii  DEHAEN  in  Hermann!  Boerhaavi,  Institutiones  Pa- 
thologicas  collegit,  recensuit,  additamentis  aurit,  edidit,  F.  de  Wasserberg.  Editio 
nova.  Coloniae-Allobrogum,  1784  ;  2  vol.  in  4°. 

^[  Institutiones  Pathologic*  medicinalis.  Jluctore  H.  D.  GAUBIO.  Leidae  Batavo- 
rum,  1758. 

**  Conspectus  PathologifB  ad  dogmata  slahliana  pracipue  adornatfB,  et  semeiolo- 
gia  Hippocratico- GalenicfB  in  forma  tab  alarum  repr&sentatus.  Jluctore  D.  J. 
JUNCKERO.  Hale-Magdeburgicae,  1736. 

ff  D.  Christ.  Gottlieb  LUDWIG,  Institutiones  Pathologies.    Lipsiae,  1767. 

^J  Joannis  ASTRUC,  Tractatus  Pathologicus,  editio  quarta.    Parisiis,  1767. 


TREATISES  ON  GENERAL  PATHOLOGY.  447 

more  or  less  complete  account  of  generally  admitted  opinions; 
some  of  them  present  different  ideas  from  those  commonly  enter- 
tained :  we  shall  confine  ourselves  to  a  concise  enumeration  of  the 
latter. 

The  General  Pathology  of  Sprengel*  first  published  in  Ger- 
man, and  afterwards  in  Latin,  is,  without  any  doubt,  one  of  the 
most  finished  works  upon  this  subject;  we  have  elsewhere  re- 
marked upon  the  plan»adopted  by  this  author,  and  have  said  that 
he  occasionally  added  peculiar  descriptions  of  diseases  foreign  to 
his  subject,  and  omitted  certain  doctrinal  points  which  seem 
naturally  to  belong  to  it;f  but  these  slight  defects  in  the  arrange- 
ment of  the  work  are  redeemed  by  the  manner  in  which  most  of 
the  subjects  are  treated.  Nearly  the  same  may  be  said  of  the 
Treatise  of  M.  Caillot,  J  published  two  years  after  the  first  edition 
of  the  present  work,  and  also  of  that  which  appeared  much  more 
recently,  with  the  same  title,  by  M.  Dubois,  of  Amiens,  one  of  the 
distinguished  physicians  of  our  times.  His  opinions  upon  the 
nature  of  disease,  and  the  limits  and  extent  of  general  pathology, 
differ  very  much  from  our  own  :  it  is  not,  however,  our  province 
to  pronounce  judgment  upon  them. 

Reil,  who  has  been  called  the  Pinel  of  Germany,  has  published  a 
work  upon  this  subject,  in  which  he  refers  all  the  phenomena  which 
are  manifested  in  the  human  body,  in  health  or  disease,  to  chemi- 
cal conditions.  If  the  composition  of  the  animal  matter  be  intact, 
health  is  the  consequence ;  disease  reveals  a  certain  change  in 
this  composition. 

Dr.  Puchelt,  Professor  of  the  Faculty  of  Heidelberg,  in  his 
Treatise  upon  Hygiene,  Pathology  and  general  Therapeutics, 
has  presented  some  ingenious  considerations  upon  the  action  of 
morbific  causes,  which  he  divides  into  mechanical  or  physical, 
which  act  upon  the  organs;  chemical,  which  act  upon  the 
humors  ;  and  dynamic,  which  act  upon  the  functions.  He  thinks 
that  the  course  of  diseases  is  subject  to  planetary  influences,  and 
particularly  to  the  lunar  phases. 

Professor  Schonlein,  one  of  the  most  celebrated  practitioners  of 
Germany,  recently  elected  to  fill  the  chair  of  general  and  special 
pathology  at  Berlin,  has  delivered  lectures  upon  this  subject,  which 
have  been  collected  and  published  by  his  pupils.  He  looks  upon 
disease  as  a  contest  between  the  principles  of  egoism  and  the 
planetary  principle,  or,  to  speak  in  terms  more  in  conformity  with 
our  language,  a  contest  between  vital  laws  and  those  which  rule 
the  universe.  The  particular  form  of  diseases  is  subordinate  to 
the  nature  of  their  productive  causes,  to  the  organ  which  re- 
ceives their  impression,  and  to  the  individuality  of  the  patient. 


*  CURTII  SPRENGEL,  Institutiones  Medica,  t  iii.,  Pathologia  generate.  Am- 
slelodami,  1813. 

t  Pa?e  4. 

J  Eternens  de  Pathologic  generate  et  de  Physiologic  pathologique,  par  L. 
Catllot,  ancien  medecin  en  chef  de  la  Marine.  Paris,  1819. 


418  TREATISES    ON    GENERAL    PATHOLOGY. 

Dr.  C.  H.  Rosch  endeavors,  in  an  ingenious  work,  to  give  to 
humoral  pathology  the  importance  it  possessed  among  the  ancients, 
and  to  establish  upon  a  basis  of  facts  the  existence  of  primary 
affections  of  the  blood  and  the  other  humors.  Dr.  HaurT,  in  a  vol- 
ume, entitled  Solidarpathologie  und  Humor  alp  athologie,  attempts 
to  disprove  the  theory  of  his  compatriot,  and  to  show  that  the 
nervous  system  is  the  spiritns  rector  vita,  the  governing  and  con- 
servative principle  of  all  the  functions.  According  to  this  system, 
chlorosis  itself  is  but  the  consequence  of  some  disturbance  of  the 
nervous  system.* 

A  defect  common  to  the  greater  number  of  the  works  we  have 
just  enumerated,  is  the  almost  universal  presentation  of  theories 
associated  with  whatever  facts  appertain  to  general  pathology, 
which  render  its  study  dangerous  when  they  are  favorable,  and 
tedious  when  they  are  abandoned.  Every  work  published  pre- 
viously to  the  close'  of  the  last  century  is  infected  with  the  humoral 
theory,  manifested  in  various  forms.  In  recent  treatises,  the 
nervous  fluid,  irritation  and  the  vital  properties,  are  unceasingly 
mingled  with,  or  substituted  for,  the  appreciable  phenomena  of 
diseases. 

There  remains  a  certain  number  of  works  which,  without  com- 
prising the  whole  of  general  pathology,  belong,  notwithstanding, 
to  the  bibliographical  history  of  that  science,  because  they  are 
devoted  to  the  elucidation  of  one  or  more  points  connected  with  it. 

In  advance  of  all  others,  we  rank  the  Treatise  on  Experience,  by 
Zimmermann^  which  is  worthy  alike  of  a  skilful  physician  and  a 
distinguished  philosopher.  The  work  of  Testa,\  upon  Periods  in 
health  and  disease,  although  it  does  not  exhibit  so  high  an  order 
of  thought,  is  no  less  important  in  a  professional  point  of  view. 
The  Pathogeny  of  Hufeland§  also  deserves  particular  attention  ; 
but  hypotheses  are  so  often  mingled  with  facts,  that  the  perusal  of 
this  ingenious  essay  is  not  without  danger  to  those  just  com- 
mencing their  professional  studies.  It  is  quite  otherwise  in  respect 
to  the  considerations  upon  general  pathology,  with  which  the  same 
author  commences  his  Manual  of  Practical  Medicine,  which  are 
the  production  of  a  rnind  matured  by  experience.  A  large  number 
of  theses  read  before  the  Faculty  of  Medicine  at  Paris,  particularly 
those  of  Bayle,  Bally,  Marandel,  etc.,  contain  an  exposition  of 
many  interesting  points  in  general  pathology.  The  Analytical  Table 
of  Chaussier  upon  health  and  disease,  the  excellent  Semeiology  of 
M.  Landre-Beauvais,  and  the  considerations  upon  general  pathol- 


*  We  are  indebted  to  Dr.  Otterburg,  of  Heidelberg,  for  information  in  regard 
to  several  German  works,  that  we  could  not  ourselves  have  consulted,  they  not 
having  been  translated. 

|  Trait't  de  V Experience  en  ginkral,  et  dans  Vart  de  guerir  en  particulier, 
traduit  par  Lefebvre  de  Villebrune.  Avignon,  1800. 

J  TESTA,  De  vitalikus  Periodis  agrotantium  et  sanorum.   Londini. 

§  If/ees  sur  la  Pathogcnie,  ou  Considerations  sur  Vinfiuence  de  la  force  vitale 
sur  I'origine  et  la  forme  des  Maladies,  par  Christ.  Will.  HUFELAND,  1795. — 
(A  long  extract  is  contained  in  the  Bibliotheque  Germanique.) 


TREATISES  OX  GENERAL  PATHOLOGY.  449 

ogy  which  constitute  the  introduction  to  the  Clinical  Medicine  of 
Professor  Rostan,  are,  morever,  works  whose  perusal  and  study 
we  cannot  too  strongly  recommend;  the  Semeiology  of  M.  Double 
may  also  be  read  with  advantage. 

The  above  are,  to  the  best  of  our  knowledge,  the  principal  trea- 
tises which  have  been  published,  both  upon  the  entire  science  and 
upon  detached  portions  of  pathology.  Many  of  these  we  have 
studied,  others  have  been  consulted,  and  certain  selections  made 
from  them  for  the  present  work.  The  course  of  instruction 
in  general  pathology  by  Professor  Andral,  will  doubtless  commu- 
nicate a  new  and  powerful  impulse  to  this  important  and  too  little 
cultivated  portion  of  medical  science.  Our  design,  we  do  not  hesi- 
tate to  repeat,  has  been  to  define  distinctly  the  limits  of  our  subject, 
endeavoring  to  attain  without  overstepping  them,  and  to  offer,  in 
an  essentially  abstract  manner,  a  doctrine  free  from  theories,  and 
founded  solely  upon  facts  and  their  immediate  and  rigorous  conse- 
quences. —  M. 

[The  only  works  that  have  been  published  upon  General  Pathology  within  our 
knowledge,  since  the  issue  of  the  last  edition  of  the  present  work,  are  the  "  Outlines 
of  Pathology,  and  Practice  of  Medicine,"  by  William  Pulteney  Alison,  M.  D.,  of 
Edinburgh  ;  and  the  Principles  of  Medicine,  comprising  General  Pathology  and 
Therapeutics,  and  a  brief  general  view  of  Etiology,  Nosology,  Semeiology,  Diag- 
nosis and  Prognosis,"  by  C.  J.  B.  Williams,  M.  D.,  of  London.  — TRANS.] 


38* 


INDEX. 


A. 


Abdomen  (symptomatology),  92:  (diag- 
nosis), 80S. 
Abscess,  by  congestion,  202;   metastatic, 

Absorption  (symptomatology),  220. 

Access,  231. 

Acquired  diseases,  64. 

Acute  and  chronic  diseases,  233. 

VEgophony,  149. 

Affections,  moral,  36. 

Affective  functions,  symptoms  furnished 
by  the,  110. 

Age,  its  influence  upon  the  seat  of  dis- 
eases, 18  ;  upon  their  production,  39; 
upon  their  prognosis,  344. 

Agents,  chemical  (etiology),  20. 

Agrypnia,  114. 

Air,  atmospheric,  32;  cold  air,  warm 
air,  32;  rnoist  air,  32 ;  unrenewed  air, 
32  ;  its  variations  of  temperature,  32  ; 
of  pressure,  33. 

Alopecia,  90. 

Alterations  of  organs,  discovered  after 
death,  357 ;  of  the  fluids,  374  ;  of  the 
gases,  377.  Some  anterior  to  the 
symptoms,  others  occur  during  the 
disease,  in  the  agony,  or  after  death. 
They  may  occur  without  there  being 
any  symptom  to  indicate  their  exist- 
ence, 379. 

Alvitie  excretion,  131 ;  matters,  131  ; 
their  nature,  131;  consistence,  132; 
color,  132;  form,  132;  odor,  133;  for- 
eign bodies,  133. 

Anaphrodisia,  226. 

Anasarca,  77. 

Animals,  parasitic,  24. 

Annual  diseases,  64. 

Anorexia,  117. 

Apnoea,  136 

Aphonia,  102;  a  prognostic  sign,  349. 

Appetite,  117  ;  venereal,  226. 

Applicata  (etiology),  23,  45. 

Aptitudes,  37,  57. 

Apyrexia,  231. 

Arteries,  symptoms  furnished  by,  170; 
auscultation  of,  179. 

Atmosphere,  its  influence  in  the  produc- 
tion of  disease,  32. 


Attack,  231. 

Attitude,  in  health,  75;  in  disease,  75; 
a  cause  of  disease,  51 ;  a  prognostic 
sign,  348. 

Auscultation,  290  ;  mediate  and  immedi- 
ate, 290;  rules  to  be  observed  in, 292; 
of  respiration,  138;  of  the  voice,  148; 
of  the  cough,  154  ;  of  the  heart,  166; 
of  the  arteries,  179  ;  its  other  applica- 
tions, 290;  in  cerebral  disease,  290. 

Authors  upon  General  Pathology,  444. 


B. 


Balbuties,  103. 

Barrenness,  226. 

Baths  (etiology),  48. 

Beds  (etiology),  48 ;  as  a  hygienic 
means,  431. 

Bellows  murmur  of  heart,  167;  of  arte- 
ries, 179. 

Bile,  secretion,  excretion  and  alterations 
of,  208,  209. 

Blood,  experiments  upon  the,  182;  al- 
terations of,  in  respect  to  color,  184  ; 
odor,  185;  taste,  185;  temperature, 
185;  separation  of  its  elements,  and 
their  modifications  in  different  dis- 
eases, 185;  foreign  substances,  186; 
deleterious  principles,  188;  gases,  189. 

Bodies,  foreign,  living  and  inanimate, 
378;  vulnerant  (etiology),  23;  their 
action,  55. 

Body,  increase  in  the  volume  of  the,  76  ; 
its  causes,  76;  diminution  in  the  vol- 
ume of,  77. 

Bones  (symptomatology),  97. 

Borborygmi,  128. 

Boulirnia,  117. 

Broncophony,  148. 

Bubo,  191. 

Buffy  coat  of  the  blood,  187. 


C. 


Calculi,  216. 
Cancer,  forms  of,  370. 
Capillary    circulation,     symptoms    fur- 
nished by,  180. 
Caries,  97. 
Carphologia,  99. 


452 


INDEX. 


Caruncula  lachrymalis  (symptomatolo- 
gy), 87. 

Carus,  115. 

Catalepsy,  101. 

Cataphora,  115. 

Causes,  definition  of,  19;  exist  around 
arid  within  us,  19;  ancient  division  of, 
20;  three  classes  of,  21  ;  their  mode 
of  action,  55;  their  obscurity  in  some 
cases,  63;  their  utility  in  diagnosis, 
31 1  ;  determining,  21  ;  common  de- 
termining, 21  ;  specific  determining, 
25;  ordinary  specific,  25;  contagious 
specific,  26  ;  their  mode  of  action,  27  ; 
predisposing,  31 ;  general  predisposing, 
32;  individual  predisposing,  36,  44; 
aptitudes,  37,  57  ;  their  mode  of  action, 
58;  occasional,  or  exciting,  53;  they 
differ  from  specific  and  determining, 
54  ;  their  mode  of  action,  55. 

Cephalalgia,  107;  often  a  sympathetic 
phenomenon,  324. 

Chattering  of  the  teeth,  118. 

Cheeks  (symptomatology),  88. 

Chemical  means,  employment  of,  in 
diagnosis,  297. 

Chemistry,  its  application  to  therapeu- 
tics, 405. 

Chest,  91  ;  its  inspection,  91  ;  percus- 
sion, 151;  auscultation,  292;  men- 
suration, 284. 

Chin  (symptomatology),  89. 

Chorea,  102. 

Chronic  diseases,  233. 

Circulation  (symptomatology),  162 ;  of 
blood,  163;  in  the  heart,  163;  arte- 
ries, 170  ;  capillary  vessels,  180  ; 
veins,  181;  of  lymph,  189. 

Circumfusa  (etiology),  22. 

Classification  of  diseases,  442. 

Climate,  influence  of,  upon  the  progress 
of  diseases,  239;  upon  their  prognosis, 
346. 

Climacteric  years,  40. 

Clonic  spasms,  100. 

Clothing,  effect  of,  as  a  cause  of  disease, 
45  ;  wet,  effects  of,  36. 

Coction,  437. 

Color  of  the  skin,  78. 

Coma,  its  two  varieties,  115;  its  diagnos- 
tic value,  324. 

Complications,  270;  their  distinction, 
271  ;  causes,  272  ;  reciprocal  influence 
of  complicated  diseases,  272  ;  are  ob- 
stacles to  diagnosis,  337;  their  prog- 
nostic value,  347. 

Compression  (etiology),  45. 

Congenital  diseases,  64. 

Conjunctiva  (symptomatology),  87. 

Consecutive  phenomena,  262. 

Constipation  (symptomatology),  129;  a 
prognostic  sign,  353. 

Constitution  (etiology),  42. 

Constitutions  medical,  65. 

Contagious  principles,  26  ;  their  proper- 


ties, 27;  origin, 29;  theory  of  Linnaeus, 
31  ;  their  action,  56. 

Contagion,  27  ;  modes  of,  28  ;  circum- 
stances which  favor  it,  28  ;  to  ascer- 
tain if  a  disease  be  contagious,  66. 

Continued  type,  231. 

Contractility,  muscular,  98;  lesions  of, 
98. 

Contractura,  102. 

Convalescence,  259;  its  phenomena, 
259;  its  duration,  261 ;  circumstances 
which  modify  it,  261 ;  a  predisposing 
cause  of  disease,  43;  therapeutics  of, 
423. 

Convulsions,  99;  clonic,  100;  tonic,  100  ; 
their  diagnostic  value,  324  ;  prognostic 
value,  349. 

Cornea,  examination  of  the,  85. 

Corns,  46. 

Corsets,  use  of,  46. 

Cough,  152  ;  its  varieties,  153;  ausculta- 
tion of,  154  ;  sympathetic,  329. 

Counter  indications,  421. 

Course  of  diseases,  230. 

Crachotment,  155. 

Cramp,  99. 

Crepitation,  97. 

Crisis,  doctrine  of,  246;  division,  245; 
theory  of,  according  to  the  humorists, 
438 ;  solidists,  438. 

Critical  days,  256 ;  phenomena,  247 ; 
signs  which  precede  and  accompany, 
248;  favorable  circumstances,  252; 
their  influence  upon  the  changes  that 
take  place,  253. 

Crocidismus,  99. 

Crudity,  437. 

Crusts,  206. 

Crystalline  (symptomatology),  86. 

Cure  (termination  of  diseases),  242; 
in  general  diseases,  243;  in  local 
diseases,  243;  in  chronic  diseases, 
244. 


D. 


Days,  critical,  doctrine  of,  256  ;  indicat- 
ing, 256;  intercalary,  non-decretory, 
257;  doctrine  of  Hippocrates,  of  Ga- 
len, 257;  medical,  mode  of  reckoning, 
240. 

Death,  termination  by,  244. 

Decline  of  diseases,  235. 

Decretory  days,  256. 

Decubitus  (symptomatology),  75 ;  a  prog- 
nostic sign,  348;  dorsal,  75;  lateral, 
76. 

Defecation,  130. 

Definition  of  disease  according  to  its 
intimate  nature,  7  ;  that  of  Sydenham, 
7  ;  of  M.  Littre,  9  ;  of  the  author,  11 ; 
of  diseases  in  particular,  11. 

Degeneration  (pathol.  anat.),  373.  See 
organic  transformations. 


INDEX. 


453 


Deglutition  (symptomatology),  123;  ac- 
celerated,  123;  difficult,   124  ;  impos- 
sible, depraved,  124;  prognostic  value 
of  disordered,  353. 
Degrees  of  diseases,  235. 
Delirium,    111  ;    its   causes    and    forms, 
112  ;  often  a  sympathetic  phenomenon, 
323  ;  its  prognostic  value,  351. 
Deposits,  urinary,  217. 
Descent,  a  predisposing  cause,  37. 
Determining  causes,  21;    common,  21; 

specific,  25. 

Deuteropathic  diseases,  69. 
Diadexis,  245. 
Diagnosis,  273;  signs  on  which  it  is 
based,  273 ;  conditions  necessary  to 
its  establishment  on  the  part  of  the 
physician  and  patient,  275;  its  prin- 
cipal elements,  311  ;  circumstances 
which  render  it  difficult  or  uncertain, 
321  ;  1st,  the  period  at  which  the  pa- 
tient is  examined,  321  ;  2d,  predomi- 
nance of  sympathetic  phenomena,  323  ; 
3d,  rareness  of  the  disease,  336;  com- 
plications, 337;  dishonesty  of  patients, 
33d  ;  diagnosis  the  foundation  of  prog- 
nosis, 343. 

Diarrhoea,  129. 

Diathesis,  59;  principal  kinds,  59. 

Digestion  (symptomatology),  117;  stom- 
achal, 125. 

Disease,  definitions  of,  6  ;  diseases  com- 
mon to  all,  or  peculiar  to  certain  tis- 
sues, 17. 

Diseases,  circumscribed,  disseminated, 
17;  innate,  congenital,  64;  acquired, 
sporadic,  64  ;  pandemic,  annual,  sta- 
tionary, intercurrent,  endemic,  64; 
epidemic,  65  ;  essential,  primitive, 
protopathic,  69  ;  symptomatic,  second- 
ary, deuteropathic,  69 ;  concealed, 
feigned,  338  ;  acute,  chronic,  233. 

Disgust,  118. 

Distinction  of  diseases  according  to  their 
causes,  64. 

Diurnal  revolution,  its  influence  on  the 
course  of  diseases,  236. 

Drinks  (etiology),  49. 

Dumbness,  104. 

Duration  of  diseases,  240;  sometimes 
uncertain,  240  ;  sometimes  fixed,  241  ; 
circumstances  which  influence,  241; 
its  influence  on  prognosis,  347. 

Dysorexia,  117. 

Dyspermasia,  224. 

Dysphagia,  124. 

Dyspnoea,  135;  sympathetic,  329. 

Dysuria,  211. 

E. 

Ears  (symptomatology),  90. 
Electricity  (etiology),  33. 
Emaciation   (symptomatology),  77,  223; 
its  prognostic  value,  348. 


Emanations,  metallic,  animal  and  vegeta- 
ble, causes  of  disease,  25. 

Emphysema,  77. 

Ernprosthotonos,  100. 

Encephaloid  disease,  370. 
Hndemic  diseases,  64. 

Eneorema,  217. 

Ephemeral  diseases,  241. 

Ephialtes,  114. 

Epidemic  diseases,  65. 

Epigenemata,  229. 

Epiphenomena,  229. 

Erections,  224. 

Eruptions,  80. 

Essential  diseases,  69. 

Etiology,  19. 

Etymology,  15. 

Evacuations,  excessive  or  suppressed, 
50,  51  ;  involuntary,  in  prognosis,  354. 

Exacerbation,  231. 

Exciting  causes,  53. 

Excreation,  155. 

Excrements,  131. 

Excreta,  50. 

Excretions  (symptomatology),  219. 

Excoriations  (symptomatology),  81. 

Exercise,  its  influence  as  a  cause  of  dis- 
ease, 51. 

Exhalations,  196;  natural,  196;  morbid, 
200  ;  artificial,  206. 

Exophthalmia,  85. 

Expectoration,  154. 

Experience,  one  of  the  bases  of  therapeu- 
tics, 403;  should  not  be  confounded 
with  experiment,  403;  the  latter  be- 
longs to  science,  the  former  to  the 
physician,  403. 

Experiment,  383. 

Experimentation,  in  therapeutics,  383; 
its  object,  383 ;  rules  to  be  observed 
in  regard  to,  383;  its  advantages  and 
inconveniences,  391  ;  cases  in  which  it 
becomes  a  duty,  392;  in  which  it 
should  never  be  attempted,  392. 

Exspuition,  154. 

Extent  (to  determine  the  extent  of  a 
disease,)  315. 

Exterior  of  the  body,  symptoms  to  be 
derived  from,  75;  its  value  in  diag- 
nosis, 298  ;  in  prognosis,  348. 

Eyebrows,  87. 

Eyelashes,  87. 

Eyelids,  86. 

Eyes,  84;  an  important  phenomenon, 
'pointed  out  by  Sanson,  in  the  diag- 
nosis of  many  diseases  of  the,  86. 

F. 

Face  (symptomatology),  81  ;  pinched, 
82;  hippocratic,  82;  opinions  of  M. 
Jadelot,  83;  motions  of,  83;  volume, 
83;  color,  84;  its  eruptions,  84. 

Facies  vultuosa,  82. 

Fainting,  116. 


554 


INDEX. 


Family  diseases,  39. 

Fatty  transformation,  872. 

Features,  alterations  of  the,  82. 

Febrile  state  or  movement,  its  diagnostic 
value,  332;  its  acute  and  chronic 
form,  332;  its  continued,  remittent, 
intermittent  type,  335. 

Feet  (symptomatology),  96. 

Fissures,  81. 

Fistula?  (symptomatology),  81. 

Flesh,  firmness  and  flaccidity  of,  78. 

Fluctuation,  81. 

Flux  cceliac,  131. 

Food,  quality  of,  36 ;  diminution  or  ex- 
cess in  quantity  of,  48. 

Forces,  vital,  356  ;  their  estimation,  408 ; 
oppression,  411  ;  therapeutical  indica- 
tion furnished  by  them,  408. 

Fortune  (etiology),  43. 

Forehead  (symptomatology),  88. 

Friction  sound  of  pleura,  147 ;  pericar- 
dium, 168;  peritoneum,  290. 

Functions,   affective,    110;  assimilative, 

•  116;  generative,  223;  intellectual, 
111;  of  relation,  75. 


G. 


Gangrene,  368. 

Gases,  irrespirable  and  deleterious,  causes 
of  disease,  22;  in  the  blood,  189;  ex- 
halation of,  200. 

Genera  in  pathology,  266. 

Generation,  phenomena  presented  in 
disease  by  the  organs  of,  94. 

Generative  functions,  symptoms  fur- 
nished by  the,  223. 

Gesta,  (etiology),  51. 

Glands,  lymphatic,  190. 

Goitre,  33. 

Granulations,  369. 

Gravel,  216. 

Grinding  of  the  teeth,  118. 

Gums,  119. 

Gurgling  in  the  stomach,  128;  in  the 
intestines,  128;  in  the  chest,  141; 
circumscribed,  142;  extending  over 
the  whole  of  one  side  of  the  chest, 
and  everywhere  uniform  as  to  rhythm 
and  intensity,  142. 


H. 


Habit  (etiology),  42;  preservative  dispo- 
sition of,  62  ;  often  furnishes  therapeu- 
tical indications,  417. 

Haemorrhages,  200;  their  divisions,  201 ; 
diagnostic  value,  326;  prognostic  value, 
356. 

Hallucinations,  108;  differ  from  illusions, 
108. 

Hair,  90. 

Head,  symptoms  furnished  by,  81. 

Health,  definition  of,  7 ;  a  predisposing 
cause,  43. 


Hearing,  alterations  in  the  sense  of,  109. 

Heart  (symptomatology),  163;  extent  of 
its  pulsations,  164 ;  its  impulse,  165; 
nature  of  the  sounds,  166;  rhythm, 
169;  sympathetic  disturbances,  325. 

Heat,  morbid,  192;  means  of  its  appre- 
ciation, 192;  increase  of,  193;  diminu- 
tion of,  194;  its  perversion,  195;  its 
prognostic  value,  355 ;  atmospheric, 

Heavenly  bodies,  their  influence  on  the 
course  of  diseases,  238. 

Hectic  fever,  diagnostic  value  of,  335. 

Hemiplegia,  98. 

Hereditary  diseases,  37. 

Hesitation  of  the  voice,  103. 

Hiccup  (symptomatology),  152;  a  prog- 
nostic sign,  354. 

Horripilation,  194. 

Humorists,  doctrine  of  the,  437. 

Hunger  (symptomatology),  117;  in- 
creased, diminished,  117  ;  depraved, 
118;  its  prognostic  value,  352. 

Hydrophobia,  124. 

Hydrops,  its  diagnostic  value,  327. 

Hygienic  means,  428;  in  acute  diseases, 
429;  in  chronic  diseases,  434. 

Hygroma,  46. 

Hypostasis,  217. 

I. 

Idiopathic,  153,  (note). 

Idiosyncrasies,  morbific,  60;  preserva- 
tive, 61. 

Ileus,  129. 

Illusions,  108. 

Imminence  of  diseases,  70. 

Impotency,  224. 

Impulse  of  the  heart,  165. 

Increase  in  stature  during  disease,  77. 

Incubation,  period  of,  70. 

Incubus,  114. 

Indications,  406;  their  bases,  406;  are 
furnished  by  the  kind  of  disease,  406 ; 
by  its  character,  its  type,  407 ;  the 
state  of  the  vital  forces,  408;  intensity 
of  the  disease,  the  periods,  412;  the 
symptoms,  413;  the  seat,  complica- 
tions, and  causes,  414;  the  tempera- 
ment, constitution,  age,  sex,  profes- 
sion, regimen,  415;  commemorative, 
416;  the  means  already  employed, 
418  ;  epidemic  constitutions,  419  ;  ten- 
dency of  disease,  419;  obscure,  421 ; 
predilection  and  antipathy  of  physi- 
cians in  regard  to  certain  indications, 
422;  prophylactic,  422;  vary  in  the 
course  of  a  disease,  427 ;  the  same 
may  be  answered  in  many  ways,  427; 
of  convalescence,  and  those  furnished 
by  consecutive  phenomena,  423. 

Infiltration,  76. 

Inflammation,  anatomical  characteristics 
of,  in  the  principal  tissues,  366. 


INDEX. 


455 


Ingesta  (etiology),  23,  48. 

Innate  diseases,  64. 

Inquietude,  physical,  76. 

Insomnia,  114. 

Institutions,  political,  36. 

Instruments,  necessary  in  necroscopy, 
359. 

Intellect,  alterations  of,  111. 

Intellectual  functions,  symptoms  fur- 
nished by,  111. 

Intemperance,  as  a  prognostic  sign,  345. 

Intercurrent  diseases,  64. 

Intermission,  period  of,  231. 

Intermittent  type,  231 

Interrogation  of  patients,  298. 

Intestinal  canal,  symptoms  furnished  by, 
]28. 

Invasion,  234;  in  prognosis,  346. 

Irritation,  theory  of,  440. 

Ischuria,  211. 


J. 


Jactatition,  76. 


Labia  majora,  95. 

Lachrymal  sac  (symptomatology),  87. 

Laughing,  i52. 

Leanness,  223. 

Lesion,   to  determine   the  nature  of  a, 

316  ;  its  degree,  318. 
Lesions,  of  structure,  365 ;  conformation, 

volume  and  color,  373. 
Lethargy,  115. 
Leucophlegmasia,  77. 
Lientery,  131. 
Light,  its  influence  upon  the  progress  of 

diseases,  237 ;  absence  of,  a  cause  of 

disease,  33. 

Limbs,  symptoms  furnished  by  the,  95. 
Lipopsychia,  115. 
Lipothymia,  ]  15. 
Lips,  88. 

Localities  (etiology),  34. 
Lochia,  225. 
Locomotion,  symptoms  furnished  by  the 

organs  of,  97. 
Lymph,  circulation  of,  189;  alterations 

of,  191. 


M. 


Magnifying  glass,  297. 

Malacia,  118. 

Mammae,  91. 

Marasmus,  77. 

Mastication  (symptomatology),  123. 

Means,  general  or  hygienic,  428;  in 
acute  diseases,  429  ;  chronic  diseases, 
434. 

Medicine  of  tradition,  404  ;  its  import- 
ance, 404. 

Medicines,  a  cause  of  disease,  49;  diffi- 


culty of  appreciating  their  influence, 
and  making  a  methodical  classification 
of  them,  425;  their  forms  and  doses,  428. 

Meibomius,  fluid  of  the  follicles  of,  207. 

Melanosis,  371. 

Menstruation,  224  ;  its  increase,  224  ; 
diminution  and  deviation  of,  225. 

Mensuration,  5i83  ;  mode  of  practising, 
and  precautions  to  be  observed  in, 

283  ;  of  the   limbs,  284  ;  of  the  chest, 

284  ;  its  results,  284  ;  in  cases  of  pleu- 
ritic  effusion,  285  ;  of  the   abdomen, 

285  ;  of  the  pelvic  diameters,  286. 
Mental  labor  (etiology),  52. 
Metallic  tinkling,  145  ;  theories  of,  145. 
Metaschematismus,  245. 
Metastasis,  metaptosis,  245. 
Meteorism    (symptomatology),    93  ;     in 

prognosis,  353 

Method,  numerical,  392. 

Merycismus,  126. 

Miasmata  (etiology),  25. 

Microscope,  applications  of,  to  the  altera- 
tions of  the  blood,  297  ;  of  mucus, 
of  pus,  297  ;  of  milk,  297  ;  of  urinary 
deposits,  218;  its  employment  in  diag- 
nosis, generally,  297. 

Milk,  its  secretion,  excretion,  deviation, 
225. 

Mode  of  examining  and  questioning  pa- 
tients, 298  ;  of  conducting  post-mor- 
tem examinations,  358. 

Movements  (etiology),  23,  51  ;  (symp- 
tom.), 98. 

Mucus,  its  properties  and  alterations, 
198. 

Murmur,  bellows,  of  heart,  167;  of  the 
arteries,  179  ;  respiratory,  138. 

Muscles  (symptomatology),  98. 

Mussitation,  102. 

Myopia,  85. 


N. 


Nails,  96. 

Nature  of  disease,  435. 

Nares  (symptomatology),  88. 

Nausea    (symptomatology),    125 ;    as    a 

prognostic  sign,  353. 
Nebula  in  the  urine,  217. 
Neck  (symptomatology),  90. 
Necroscopy,  mode  of  procedure  in,  358. 
Night,  its  influence  upon   the  course  of 

diseases,  237. 
Nightmare,  114. 
Nomenclature,  pathological,  13. 
Nose  (symptomatology),  88. 
Numerical  method,  392. 
Nutrition  (symptomatology),  222. 

O. 

Observation,  the  basis  of  therapeutics, 
383  ;  conditions  for  a  correct  mode  of, 
in  medicine,  381  ;  the  spirit  of,  382. 


456 


INLEX. 


CEdcma,  77. 

Opisthotonos,  100. 

Organs  of  locomotion  (symptom.),  97. 

Orthopncea,  135. 

Ossification,  373. 

P. 

Palpation.  278;  mode  of  performing, 
278. 

Pain  (symptomatology),  105  ;  its  causes, 
105;  its  effects,  105  ;  its  modifications, 
106  ;  intensity,  106;  type,  107  ;  varie- 
ties, and  different  names  according  to 
its  seat,  107  ;  prognostic  value,  350. 

Pancreatic  fluid,  210. 

Pandemic  diseases,  64. 

Paralysis,  98;  its  diagnostic  value,  325. 

Paraplegia,  98. 

Parasitic  animals,  24. 

Parotid  regions  (symptomatology),  89. 

Parotis,  89. 

Paroxysms,  231. 

Passions  (etiology),  24,  52  ;  (symptom- 
atology), 110. 

Pathognomonic  signs,  274. 

Pathology,  1  ;  its  definition  and  import- 
ance, 1  ;  its  extent,  2  ;  divisions,  2  ; 
general,  3:  its  advantages  and  dan- 
gers, 4  ;  principal  treatises  upon,  444. 

Pectoriloquy,  150. 

Pellicle,  urinary,  217. 

Penis  (symptomatology),  94. 

Percepta  (etiology),  52. 

Percussion,  a  method  of  exploration, 
286;  mediate,  immediate,  287;  rules 
to  be  observed  in  its  performance,  288  ; 
in  diseases  of  the  pleura  and  lungs, 
151 ;  of  the  heart,  170  ;  of  the  abdo- 
men, 289. 

Periodical  diseases,  231, 

Periodicity  of  diseases,  233 ;  its  causes, 
233. 

Periods  of  disease,  233. 

Perspiration,  196. 

Pharynx  (symptomatology),  123. 

Phenomena,  72  ;  precursory,  70  ;  value 
of,  in  prognosis,  346  ;  consecutive, 
262;  their  progress,  264;  duration, 
264;  diagnostic  value,  319;  sympa- 
thetic, 227. 

Phlyctaena?,  85. 

Physiognomy  in  health,  82;  in  disease, 
82;  a  means  of  prognosis,  349. 

Pica,  118. 

Pinched  countenance,  82. 

Pleurosthotonos,  101. 

Plicatures  (symptomatology),  80. 

Poisons  (etiology),  23;  their  divisions, 
23. 

Political  institutions  (etiology),  36. 

Popular  diseases,  64. 

Precursory  signs,  70  ;  value  of,  in  prog- 
nosis, 346. 

Predisposing  causes,  vide  Causes. 


Predispositions,  not  to  be  confounded 
with  predisposing  causes,  59. 

Pregnancy  (etiology),  44  ;  its  influence 
upon  the  progress  of  diseases,  240  ;  on 
their  prognosis,  345. 

Preludes  of  diseases,  70. 

Presbyopia,  85. 

Pressure  (diagnosis),  276 ;  differs  from 
palpation,  276  ;  signs  which  it  fur- 
nishes, 277. 

Primary  diseases,  69. 

Probes,  examination  with,  293. 

Prodromes,  70. 

Professions  (etiology),  43. 

Prognosis,  341  ;  conditions  necessary  to 
its  establishment,  341. 

Prognostic  signs,  342  ;  principal,  348. 

Progress  of  diseases,  230  ;  its  importance 
in  prognosis,  347. 

Protopathic  disease,  69. 

Ptosis,  99. 

Ptyalism,  207. 

Puerperal  state,  345. 

Pulse,  170  ;  its  frequency  according  to 
age,  170;  mode  of  examining,  172; 
its  varieties,  172 ;  venous,  182  ;  criti- 
cal, 250;  its  prognostic  value,  354. 

Pupils  (symptomatology),  85. 

Purring  tremor,  168. 

Pus,  physical  and  chemical  properties  of, 
204. 

Pyogenia,  201  ;  formation  of  pus,  201  ; 
its  diplacement,  202;  physical  and 
chemical  qualities,  204. 

R. 

Reasoning  in  medicine,  405. 

Recurrence,  265;  its  causes,  265  ;  symp- 
toms, 265. 

Regurgitation,  125. 

Relapse,  264  ;  its  causes,  264  ;  symptoms, 
265. 

Remedies,  precautionary,  a  cause  of  dis- 
ease, 50  ;  differ  from  treatment,  427  ; 
their  number  infinite,  427. 

Remittent  type,  232. 

Renvois,  125. 

Repercussion,  242. 

Residence,  34. 

Resolution,  242. 

Respiration  (symptomatology),  134;  fre- 
quent, 134;  quick,  135;  full,  135; 
small,  135;  laborious,  135;  painful, 
135;  suffocating,  135;  unequal,  136; 
irregular,  136;  intermittent,  136;  in- 
terrupted, 136  ;  sighing,  136  ;  plain- 
tive, 136  ;  resembling  the  sound  of  a 
flute,  136;  stertorous,  137;  rattling, 
137. 

Respiratory  murmur,  in  its  normal  con- 
dition, 138;  is  not  of  equal  intensity 
in  all  parts  of  the  chest,  138  ;  its  modi- 
fications in  disease,  138. 

Restlessness,  76. 


INDEX. 


457 


Retching,  125. 

Return  to  health,  242  ;  in  general  dis- 
eases, 243  ;  local  diseases,  243  ;  chronic 
diseases,  244. 

Revolution,  diurnal,  its  influence  on  the 
progress  of  diseases,  237. 

Rhonchi,  definition  of,  140  ;  crepitant, 
140;  subcrepitant,  141  ;  mucous,  141  ; 
cavernous,  14]  ;  sibilant,  144 ;  sono- 
rous, 144. 

Rhythm  of  the  cardiac  pulsations,  169. 

Rigidity,  99  ;  a  prognostic  sign,  349. 

Rigor  (symptomatology),  194  ;  as  a  prog- 
nostic sign,  355. 

Risus  sardonicus,  89. 

Rumination,  126. 


Saliva,  207. 

Satyriasis,  224. 

Scabs,  206. 

Schirrus,  370. 

Scrotum,  95. 

Seasons,  a  cause  of  diseases,  33  ;  their 
influence  on  the  seat  of  diseases,  18  ; 
on  their  progress,  238  ;  on  their  prog- 
nosis, 346. 

Seat  of  diseases,  16;  to  determine  the, 
312;  its  prognostic  value,  344  ;  influ- 
ence of  age  upon  the,  18;  influence 
of  the  seasons,  18. 

Secondary  diseases,  69. 

Secretions,  206. 

Sediment,  217. 

Semen,  secretion  and  excretion  of,  224. 

Sensations,  internal,  105;  external,  108. 

Sensibility,  104. 

Sexes  (etiology),  41. 

Shoulders  (symptomatology),  91. 

Sighing  respiration,  136. 

Sight,  alterations  of,  108. 

Signs,  differ  from  symptoms,  72 ;  pre- 
cursory, 70  ;  diagnostic,  273 ;  their 
division,  274  ;  prognostic,  342. 

Skin,  its  various  colors,  78;  spots,  79; 
eruptions,  80  ;  plicatures,  80  ;  tumors, 
excoriations,  81 ;  fissures,  fistulas,  ul- 
cers, &c.,  &c.,  81. 

Sleep  and  the  waking  state,  as  causes, 
52;  symptoms,  113;  prognostic  value 
of,  351. 

Sleeplessness,  114. 

Smell,  exaltation  and  diminution  of,  109. 

Sneezing,  152. 

Solidists,  doctrine  of  the,  438. 

Somnolency,  115. 

Sopor,  115. 

Souffle,  vide  Respiratory  murmur,  and 
Bellows  murmur. 

Sounds,  respiratory,  138;  of  the  heart, 
166;  bellows,  167;  filing,  167;  rasp- 
ing, 167  ;  musical,  167;  sawing,  167; 
auriculo-metallic,  168  ;  friction,  of 
pleura,  147  ;  pericardium,  168  ;  peri- 
39 


toneum,  290;  arterial,  179;  examina- 
tion with  probes  and,  293. 

Species  of  disease,  266. 

Specific  causes,  common,  25. 

Speculum,  294  ;  cavities  explored  by  this 
instrument,  294;  mode  of  its  intro- 
duction into  the  vagina  and  rectum, 
295. 

Speech,  anomalies  of,  103. 

Spitting,  155. 

Sporadic  diseases,  64. 

Sputa  (symptomatology),  155  ;  their  dif- 
ferences, 156  ;  they  furnish  important 
prognostic  signs,  354. 

Sputation,  156. 

Stages,  236. 

Stationary  diseases,  64. 

Statistics,  medical,  393;  its  application, 
393;  objections  to  it,  with  their  refu- 
tation, 395. 

Sterility,  226. 

Stammering,  103. 

Strangury,  211. 

Stature,  rapid  increase  of,  a  prognostic 
sign,  349. 

Strength,  356;  estimation  of  the,  408; 
oppression  of  the,  411  ;  therapeutical 
indications  furnished  by  the  state  of 
the,  408. 

Stupor,  82. 

Subsultus  tendinum  (symptomatology), 
99;  as  a  prognostic  sign,  349  ;  epigas- 
tric, 125. 

Succussion,  abdominal,  282;  thoracic, 
146. 

Supervenientia,  229. 

Suppuration,  204,  242. 

Suspension  in  the  urine,  217. 

Sympathetic  phenomena,  227;  render 
diagnosis  obscure,  323. 

Sympathies,  morbid,  227. 

Symptomatic  phenomena,  considered  in 
relation  to  diagnosis,  319. 

Symptomatic  diseases,  69. 

Symptomatology,  72. 

Symptoms,  72;  differ  from  signs  and 
phenomena,  72  ;  division  of  Boerhaave, 
of  Bayle,  73;  order  followed  in  their 
exposition,  74  ;  primary  or  local,  227; 
secondary  or  general,  227  ;  sympa- 
thetic, 227;  idiopathic,  153;  principal, 
228;  accessory,  228  ;  active,  229;  pas- 
sive, 229;  of  a  symptom,  230;  of  a 
cause,  230. 

Syncope,  116. 

Synonomy  of  diseases,  15. 

T. 

Taste  (symptomatology),  109. 

Tears,  207. 

Teeth  (symptomatology),  118. 

Temperaments  (etiology),  41. 

Tempies,  88. 

Tenesmus,  130  ;  vesical,  211. 


458 


INDEX. 


^Termination  of  diseases,  242;  by  their 

Mure,  242  ;  by  death,  244  ;  by  the  su- 

;.' .  pervention  of  another  disease,  245. 

•Testicles  (symptomatology),  95. 

Therapeutics,    380  ;    its    bases,   observa- 

$$  tion,  381;  and  experience,  403;  em- 

'  ployment  of  reasoning,  405;  applica- 
tion of  chemical  knowledge,  405. 

Thirst   (symptomatology),  118  ;  a  prog- 

I  nostic  sign,  352. 

Time,  between   the   application    of  the 

£  cause  and  the  development  of  the 
disease,  69. 

Tinkling,  metallic,  145. 

Tongue,  in  health,  119  ;  in  disease,  119 ; 
its  volume,  120;  form,  120;  motions, 
120  ;  color,  120  ;  coats,  121 ;  humidi- 
ty, 122  ;  eruptions,  122  ;  temperature, 
123  ;  sensibility,  123 ;  signs  which  it 
furnishes  to  prognosis,  352. 

Touch,  sense  of  (symptomatology),  109  ; 
exploration  by  the,  280 ;  mode  of  its 
performance,  280  ;  by  the  vagina,  280 ; 
the  signs  it  furnishes,  281  ;  by  the 
rectum,  281  ;  in  the  pharynx,  282. 

Transformations,  morbid,  372 ;  cartila- 
ginous, 373  ;  cutaneous,  372  ;  fibrous, 

;    373  ;  fatty,  372  ;  horny,  373  ;  mucous, 

I  372  ;  osseous,  373  ;  serous,  372. 

Trembling,  99. 

Trismus,  101. 

Tubercles,  368. 

^Tumors,  81. 

i  Tunica  vaginalis,  95. 

•Tympanites,  93. 

EType   of  diseases,  231  ;  continued,  231 ; 

>•  periodical,  231  ;  varieties  of  intermit- 

I  tent,  231  ;  remittent,  232  ;  an  element 

^  in  their  diagnosis,  320. 


U. 


Ulcers,  367.     - 

Univocal  signs,  274. 

Urine,  the  normal  properties  of,  210  ;  the 
changes  in  its  physical  and  chemical 
properties,  and  in  its  excretion,  211  ; 
its  deposits,  217. 


V. 


Vapors,  metallic  (etiology),  25. 

Variations  of  the  atmosphere,  32  ;  their 
influence  upon  the  progress  of  dis- 
eases, 238. 

Varieties  of  disease,  270. 

Veins  (symptomatology),  181. 

Venomous  secretions,  26. 

Vertigo,  116. 

Vessels,  lymphatic  (symptomatology), 
189. 

Vibices,  80. 

Virus,  26  ;  mfo  Contagious  principles. 

Vision,  108. 

Voice,  102;  auscultation  of  the,  148. 

Volume  of  the  body,  76. 

Vomited  matters,  126. 

Vomiting,  126;  sympathetic,  126. 


W. 

Winds,  influence  of  the,  32. 

Y. 

Yawning,  152. 
Years,  climacteric,  40. 


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